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GERIATRICS 



N ASCH ER 



GERIATRICS 

THE 

DISEASES OF OLD AGE AND THEIR 
TREATMENT 



INCLUDING PHYSIOLOGICAL OLD AGE, HOME 
AND INSTITUTIONAL CARE, AND MEDICO- 
LEGAL RELATIONS 



; '■^ BY 

lA. NASCHER, M. D. 

NEW YORK 



With an Introduction by 
A. JACOBI, M. D; 



WITH 50 PLATES 
CONTAINING 81 ILLUSTRATIONS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 






Copyright, 1914, by P. Blakiston's Son & Co. 



THB*MAFIiB*PBESS>TOBK«PA 

FEB -7 1914 

©CI.A362475 



PREFACE 

No American work on senile diseases has appeared in over 
thirty years, the last being Charcot and Loomis' "Diseases of 
Old Age" published in 1881. Even that was not distinctively 
American for it was a translation of the published lectures 
delivered in the sixties by the great French physician in La 
Salpetriere, the home for the aged in Paris, to which were added 
ten lectures by Doctor A. L. Loomis of New York. Since then 
a lengthy article by Doctor A. Seidel of Berlin appeared in 
Wood's Monographs for March, 1890, and there have been a 
ntimber of journal articles on various senile conditions, but no 
American work dealing with the subject as a whole has ever been 
published. The neglect of senile diseases (except arterio- 
sclerosis which has received some attention in recent years) 
is evident from the paucity of literattu-e on the subject. The 
cause of this neglect must be sought in the general mental at- 
titude toward the aged. The spirit of veneration of ancestors 
and the aged, such as exists in China, does not exist among us. 
The sentimental interest in the aged is confined to the immediate 
family of the individual and there the interest is often less senti- 
mental than dutiful. We realize that for all practical purposes 
the lives of the aged are useless, that they are often a burden 
to themselves, their family and to the community at large. 
Their appearance is generally unesthetic, their actions objec- 
tionable, their very existence often an incubus to those who in 
a spirit of humanity or duty take upon themselves the care of 
the aged. Those who would deny that this is the usual attitude 
toward the aged need but compare the treatment of the uncared- 
for child with the treatment of the uncared-for old man, the 
asylums for children with the asylums for the aged, the treat- 
ment in the home where children and their grandparents entail 
burdens upon the family. The physician views the aged from 
a different standpoint. As a humanitarian it is his duty to 
prolong life as long as there is life and to relieve distress wherever 
he may find it. There is, however, a nattiral reluctance to exert 

V 



VI PREFACE 

oneself for those who are economically worthless and must re- 
main so, or to strive against the inevitable, though there be 
the possibihty of momentary success, or to devote time and 
effort in so unfruitful a field when both can be used to greater 
material advantage in other fields of medicine. Still these ob- 
jections are paltry when applied to the physician's self-imposed 
obligation to relieve distress and prolong life. There is another 
point of view from which the physician should consider the aged 
and their diseases, that of the scientist, for here is a most interest- 
ing study, presenting problems that are intimately bound up in 
the grand mystery of life and death. In this direction the 
French and German investigators are far ahead of their Ameri- 
can confreres, not so much in the quality of work done and posi- 
tive results achieved, as in the quantity, the number of investiga- 
tors, the many lines of investigation, and the opportunity afforded 
them to carry on scientific research. There the State takes an in- 
terest in scientific work, lending its aid, and there is substantial 
recognition of work accomplished. The lack of opportunity to 
carry on research work in this country except at a heavy ex- 
pense to the individual, or else at the sacrifice of the credit and 
benefit arising from successftil research work, is probably the 
main reason for the neglect of the scientific study of senility and 
its diseases. In recent years considerable work has been done 
in blood-pressure investigations, cancer research, arteriosclero- 
sis and other factors related to senility and its diseases. The 
extent and depth of these investigations, which are really studies 
into the causes and results of senile changes, and the ever-in- 
creasing scope of these investigations, give promise of ultimate 
success in discovering the fundamental causes of senescence. 
Perhaps there may be controllable causes or causes which can be 
minimized so as to defer senility and prolong life to its physio- 
logical end. The prolongation of life is after all the aim and 
goal of the physician's endeavors. The author acknowledges 
his deficiencies both as a writer and investigator. Much of 
the histological and pathological data have been culled from 
other recent works, mainly German and French, but their erudite 
theories have been omitted except where theoretical discussions 
were necessary as in the chapter on causes of ageing. In nomen- 
clature, the author follows the tendency of American writers 
to use English terms rather than the more scientific but often 



PREFACE Vll 

more complex and less understood Latin terms used by Euro- 
peans. A few new terms are introduced where the old terms 
are complicated as "Grawitz' cachexia" to cover the disease he 
described under the name ''fatal cachexia without discernible 
anatomical cause;" ''Ortner's syndrome" for the disease he de- 
scribed as '' dyspragia intermittens angiosclerotica intestinalis." 
The word senile is prefixed to diseases that present different fea- 
tures in senihty from those of earlier life. Other terms like hypo- 
static edema, psychic senile debiHty, etc., will be readily under- 
stood. The classification is new. Lengthy descriptions have 
been avoided, minute pathology has been generally omitted, 
and only the essential symptoms necessary to recognize a dis- 
ease and differentiate it from others have been introduced. It 
seems superfluous to describe every symptom that may appear 
in a disease in old age, which differs in but a few essentials from 
the similar disease of maturity, especially when the physician 
should know the disease as it appears in maturity or can get a 
description from the ordinary text -books. Greater stress has 
been laid upon the treatment of diseases and the differential 
diagnosis between normal senile conditions and pathological 
conditions which they simulate, as this branch of geriatrics has 
been generally neglected. 

In presenting this work to the medical profession the author 
hopes to arouse an interest in geriatrics and stimulate research 
into the causes of senescence and the pathology of senile dis- 
eases. It is not too much to expect that as a result of such 
interest and research we will get a better knowledge of the senile 
organism and be more successful in coping with senile diseases 
than we are at present. Believing that attention would be 
more readily concentrated upon this subject if it were con- 
sidered entirely apart from maturity, the author suggested that 
it be studied as a special branch of medicine to which he ap- 
plied the term geriatrics. This term which has been generally 
adopted is derived from the Greek, geron, old man, and iatrikos, 
medical treatment. The etymological construction is faulty 
but euphony and mnemonic expediency were considered of 
more importance than correct grammatical construction. 

I desire to express my gratitude to the authors and radio- 
graphers who have furnished me with cuts and illustrations and 
the permission to use their illustrations which appear in this 



Vm PREFACE 

work ; also to the Journal of the American Medical Association, 
Medical Record, and New York Medical Journal, in which some 
of these illustrations first appeared ; and to Doctor Alexander 
Klein of Philadelphia for his careful revision of the entire work. 

I would also like to express my gratitude to Doctor Robert 
Abrahams and the Medical Staff of the Home of the Daughters 
of Jacob, New York, and to Doctor W. Travis Gibb and the 
Medical Board of the New York City Home for the Aged and 
Infirm, and the General and Neurological Hospital for the 
opportunities given me to study cases at those institutions. 

Some of the material in this work appeared in the author's 
papers which were published in the N. Y. Medical Joiu-nal, 
Medical Record, Medical Times, American Medicine, American 
Practitioner, Archives of Diagnosis, Dietetic and Hygienic 
Gazette, all of New York; International Clinics and Medical 
Council of Philadelphia ; and Am. Journal of Clinical Medicine 
of Chicago. 

I. L. Nascher. 



CONTENTS 



Pagb 

Preface v-viii 

Introduction by A. Jacobi, M. D xi-xiv 

Childhood and Old Age i 

PHYSIOLOGICAL OLD AGE ii 

The Senile State ii 

Anatomical Changes in Old Age 21 

Physiological Changes in Old Age 31 

Causes of Ageing 38 

PATHOLOGICAL OLD AGE 51 

General Considerations 51 

Classification of Diseases in Old Age 65 

Primary Senile Diseases 67 

Senile Cachexia 67 

Senile Arteriosclerosis 74 

Senile Phlebosclerosis 94 

Senile Degeneration of the Heart 95 

Senile Myofibrosis 96 

Brown Atrophy 99 

Senile Endocarditis lOO 

Senile Degeneration of the Lungs loi 

Senile Pneumokoniosis 103 

Senile Degeneration of the Oral Cavity 104 

Senile Degeneration of the Stomach 106 

Gastric Atonicity 106 

Dilatation of the Stomach 108 

Pyloric Insufficiency 109 

Senile Degeneration of the Intestines no 

Senile Constipation ,, no 

Atony of the Sphincter Ani 113 

Senile Degeneration of the Liver 114 

Senile Degeneration of the Gall Bladder 115 

Senile Degeneration of the Kidney 116 

Senile Degeneration of the Bladder 117 

Senile Degeneration of the Male Genitals 120 

Senile Degeneration of the Prostate 122 

Senile Degeneration of the Female Genital Organs 124 

Senile Degeneration of the Ductless Glands 127 

Spleen 128 

Thyroid Gland 129 

Suprarenal Glands 129 

Senile Degeneration of the Skin 130 

Alopecia 132 

Hypertrichosis 133 

ix 



CONTENTS 

Page 

Canites . 133 

Degeneration of Sudoriparous Glands 134 

Senile Muscular Degeneration 134 

Senile Arthrosclerosis 136 

Pseudo Paget's Disease 138 

Senile Degeneration of the Brain 138 

Senile Degeneration of the Cord 145 

Senile Myelitis 146 

Senile Tremor 148 

Senile Degeneration of the Nerves and End Organs 150 

Senile Degeneration of Organs of Special Sense 152 

Senile Pruritus 154 

Varicose Veins . 156 

Secondary Senile Diseases 157 

Thrombosis and Embolism 157 

Senile Gangrene 164 

Cardiac Neuroses 166 

Palpitation 167 

Bradycardia 168 

Tachycardia 196 

Adams-Stokes Disease 170 

Arrhythmia 171 

Angina Pectoris 174 

Senile Bronchitis 178 

Senile Gastric Catarrh 180 

Gastric Neuroses 185 

Oesophageal Neuroses 187 

Intestinal Neuroses 188 

Cholelithiasis 188 

Senile Metritis 191 

Cerebral Anemia 193 

Alternating Cerebral Anemia and Hyperemia 193 

Cerebral Softening 195 

Cerebral Hemorrhage 198 

Senile Neuritis 203 

Senile Trifacial Neuralgia 204 

Modified Diseases of Old Age 206 

Hay Fever 207 

Senile Asthma 208 

Pleurisy 209 

Pulmonary Hyperemia 214 

Senile Pneumonia 216 

Senile Acute Gastritis 223 

Simple Chronic Gastritis 225 

Senile Diarrhea 226 

Senile Cystitis 228 

Modified Diseases of the Skin 229 

Senile Purpura 230 

Senile Angioma 231 

Senile Sebaceous Naevi 232 

Senile Keratoma 232 



CONTENTS XI 

Page 

Senile Warts 233 

Rosacea 234 

Dermatides with Minor Modifications 236 

Chronic Ulcer 244 

Neoplasms, Benign 246 

Malignant 247 

Sarcoma 249 

Senile Psychoses 251 

Modified Psychoses 255 

Senile Psychasthenia 257 

Senile Neurasthenia 259 

Senile Epilepsy 262 

Neuroses of the Aged 264 

Insomnia 265 

Neuralgia 266 

Preferential Diseases of Old Age 268 

Carcinoma 268 

Oral 270 

Laryngeal 272 

Lung 273 

Pleura 273 

Mediastinum 274 

Oesophagus 274 

Stomach 275 

Intestines 277 

Liver 279 

Gall-bladder 280 

Pancreas . • 280 

Prostate 281 

Bladder 282 

Testicle 282 

Scrotum 283 

Penis 283 

Female Genital Organs 283 

Breast 284 

Grawitz' Cachexia 284 

Chronic Laryngitis 285 

Chronic Hypertrophic Bronchial Catarrh 286 

Pulmonary Edema 288 

Pulmonary Gangrene 290 

Pulmonary Abscess 293 

Cardiac Hypertrophy 294 

Cardiac Dilatation 296 

Fatty Degeneration of the Heart 300 

Fatty Infiltration of the Heart 301 

Valvular Lesions 302 

Aortic Regurgitation 306 

Aortic Stenosis 309 

Mitral Regurgitation 311 

Mitral Stenosis 313 

Tricuspid Regurgitation 314 



XU CONTENTS 

Pagb 

Combined Valvular Lesions 315 

Intestinal Obstruction 320 

Hemorrhoids 327 

Biliary Obstruction . . . . 329 

Chronic Interstitial Nephritis 332 

Urolithiasis 337 

Senile Metrorrhagia 342 

Chronic Rheumatism 344 

Arthritis Deformans 346 

Paget's Disease 350 

Gout . 351 

Diabetes Mellitus 358 

Cerebral Hyperemia 376 

Paralysis Agitans 377 

Progressive Bulbar Paralysis 379 

Acute Bulbar Paralysis 381 

Pseudo Bulbar Paralysis 381 

Diseases Uninfluenced by Age 382 

Infectious Diseases 382 

Scarlatina 383 

Measles 384 

Diphtheria 384 

Whooping Cough 386 

Mumps 386 

Malaria 386 

Yellow Fever 387 

Dysentery 388 

Plague 390 

Cholera 390 

Variola 391 

Varioloid 392 

Typhoid 392 

Typhus 399 

Influenza 401 

Acute Endocarditis 403 

Infectious Pneumonia 405 

Tuberculosis 411 

Fibroid Phthisis 412 

Miliary Tuberculosis 415 

Relapsing Fever 417 

Cerebrospinal Meningitis 417 

Acute Articular Rheumatism 419 

Erysipelas 419 

Sepsis 421 

Gonorrhea 4^5 

Syphilis 426 

General Anemia 429 

Pernicious Anemia 432 

Leukemia 434 

Pseudoleukemic Diseases 43^ 

Rhinitis 436 



CONTENTS XIU 

Page 

Diseases of the Throat 438 

Laryngeal Diseases 440 

Diseases of the Thyroid Gland 443 

Diseases of the Adrenal Glands 444 

Acute Bronchitis 444 

Bronchial Stenosis 446 

Pericarditis 447 

Gastric Ulcer 448 

Duodenal Ulcer 450 

Enteritis 450 

Diseases of the Liver 456 

Diseases of the Peritoneum 460 

Diseases of the Pancreas 462 

Diseases of the Spleen 463 

Diseases of the Kidneys 464 

Hyperemia 464 

Nephritis 467 

Pyelitis 468 

Myalgia 468 

Myositis 470 

Meniere's Symptom Complex 47I 

Osteomalacia 472 

Osteomyelitis 474 

Spinal Diseases 474 

Cerebral Diseases 475 

HYGIENE AND MEDICO-LEGAL RELATIONS 

Home Care of the Aged 477 

Institutional Care of the Aged 485 

Medico-legal Relations 497 

Marriage 503 

Sexual Perversions 504 

Malingerers 506 

Index 511 



INTRODUCTION 



The physiology, pathology and therapy of early age have 
been extensively studied and discussed in our country these 
fifty years. Whatever American contributions to pediatrics 
there were before 1800, could easily be enumerated on a few 
pages of "Janus, 1900." After that time there were a few books 
by Dewces, Eberle, Stewart, Condie and Meigs, but the interest 
in pediatrics of otir medical profession was not an animated 
one imtil half a century ago. That was for Europe the time of 
the epochmakers RilHet and Barthez, Charles West, and Karl 
Gerhardt. With us pediatric literature and the taste for it, 
and the appreciation of its necessity and dignity have deservedly 
grown since. Magazine articles, laboratory and bedside reports, 
pamphlets and comprehensive books — some say too many — 
have increased to such an extent as to form a voluminous 
library. Possibly, however, not all of these works, mainly 
the deluge of text books on the diseases of children, are indis- 
pensable, many may have been merely the offsprings of the 
author's autosuggestions. Still, even they demonstrate the 
force of the new movement and the extent of the new market. 
A few special journals have also proven the growing interest in 
pedology which was exhibited both by the profession and the 
teachers who are mostly guided by the suggestions and demands 
of the medical public as represented in our large city, state, and 
national associations. This tendency, however, has forttmately 
not succeeded in building up a new specialty with all its narrow- 
ing influences; on the contrary, it has broadened the horizon 
of honest students and made better general practitioners out of 
those whose main endeavors were diverted to understanding 
all about the young. At the same time those whose interests 
were originally confined to the study of and practice among 
the people at large, added to their intellectual capital by acquir- 
ing the results of specialistic labors in pediatrics. I am quite 
stire that the pediatrist cannot succeed in his practical work 
without being a close student of nosology in general, and on the 

XV 



XVI INTRODUCTION 

other hand, that the '* internist,'* the general practitioner and 
physician does not, without being at the same time a pediatrist, 
reach a standard by which he may be of real use either at the 
individual bedside, or as a sanitarian in the coimcils of the nation. 
The world is entitled to demand of every one of us a complete 
knowledge of and profound interest in the physical life both of 
the young and the old. 

Now why is it that the growing interests in many of the 
branches of medical science and practice has not equally been 
extended to the diseases of old age? It might properly be 
measured by the literature of the subject; but it has not mani- 
fested itself by books or pamphlets or magazines, nor by a 
specialistic instruction in our American schools of medicine. 
Nor has any of our great and influential associations insisted 
upon the appropriate enlargement of the medical curricula of 
our teaching institutions. Our American literature is poverty 
stricken, comparatively. For the brilliant labors of C. S. Minot 
in part published in the Popular Science Monthly, with his 
"Problem of age, growth and death" (London, 1908) has not 
yet fertilized our desert. The British literature to which we 
should resort, is not much richer. Day, 1849, Mclaghlan, 1863, 
G. M. Humphrey, 1885, G. W. Balfour, 1894, Clifford Albutt, 
1896 are the only books which have treated of old age, mono- 
graphically. A few translations, mainly that of Charcot's 
lectures on senile diseases contained in the new Sydenham 
society's publications (vol. 95) 1881 furnish the best there was 
of what now-a-days is considered old literature. Finally the 
eternally young Sir Herman Weber has given us in two editions 
of **on means for the prolongation of life" in his best style 
his philosophical and clinical views on how to remain yoimg 
when advanced in years, and Robert Soundby acknowledging 
the defects of the literature of his country, has published a 
very competent clinical guide ("Old age, its care and treatment 
in health and disease," London, 1913). 

France has not been very productive. Still, after Gillette, 
185 1, and Reveille-Paris, 1853, Charcot's original work was a 
great achievement, rich and fertile. He was followed by 
Demange in 1886. Boy-Teissier's lectures of 1895 and G. 
Rauzier's book of 1909 are valuable and influential works. 
The latter seem to have diverted the attention of young 



INTRODUCTION XVU 

authors to the subject which was rather neglected; indeed 
during the last few years more than a dozen Paris inaugural 
theses have been published; they treat monographically of old 
or senile organs. 

Germany has proven its supremacy as the modern leader 
in medical science through its contributions to what Doctor 
Nascher proposes to teach under the heading of geriatrics. After 
Fischer's Tract atus de senio, 1766, comprehensive treatises have 
been furnished by Canstatt, 1839; Geist, i860; Mettenheimer, 
1863; F. W. Muller, 1863; Seidel, 1889; Muhlmann, 1900; 
F. Friedmann, 1902; Schwalbe, 1909 Lindheim, 1909 and Arne 
Faber, 19 12. Avast nimiber of German monographs, clinical, 
pathological, histological and therapeutical, have added to our 
knowledge. Aschoff 's many studies published during the last few 
years will long be our guides in the appreciation of the dignity 
and import of the advancing changes of the blood-vessels. 

Dr. Nascher has undertaken to write, what for our coimtry 
seems to be the first modern comprehensive book on the normal 
and the morbid changes of old age. He has honored me by 
permitting me to accompany it with this introduction to the med- 
ical public. This work has been suggested to him by his scien- 
tific interest, continued study and humane sympathy. He does 
not mean to take the sufferings of old age and early death for 
granted, and for welcome dispensations of providence. That 
may be the point of view sufficient for the statistician, while the 
individual, beyond the threatened premature decay, has a 
justifiable claim to comparative health, persistent comfort, and 
uninterrupted efficiency. These are the great assets of the indi- 
vidual who looks for competency and enjoyment, and of the 
human society which has a right to demand cooperative services 
from all. For premature incompetency and premature death 
mean private and collective bereavement. It is the domain of 
the physician for whom this book is written to combat them. If 
it be correct that sclerosis and atheromatosis and cell atrophy and 
malignant proliferations are natural results of histological changes 
resulting in vital retrogression or malignant degeneration, and 
in sufferings and dangers, they can and should be delayed and 
rendered less formidable or even innocuous by the very props and 
staffs of childhood and adult Hfe, viz., hygiene, diet, drugs and 
surgical aids. 



XVIU INTRODUCTION 

The study of advanced age will enhance the competency of 
the physician to the same degree to which it was advanced by 
the closer knowledge of the physiology and pathology of the 
infant and child. With this difference: the baby offers but few 
difficulties in arriving at a diagnosis. His diseases are simple. 
He has only one at a time. Complications are infrequent, but 
the perplexities grow from decade to decade. For there are only 
few diseases that leave no remnants. The recovery from every 
new disease contracted at any period of life is handicapped by 
the tissue changes left behind from previous accidents or ail- 
ments. There are few persons of advanced years without a 
permanent blemish — one or many — which make the diagnosis of 
any additional illness or morbid condition more difficult, treat- 
ment more uncertain, and complete recovery more doubtful. 
That is why I imagine that Doctor Nascher by offering the prac- 
titioner of medicine this book, will render him a meritorious 
service. 



/t 1 MtU 



GERIATRICS 



CHILDHOOD AND OLD AGE 

Senility is often called Second Childhood. A comparison 
of the organism in childhood with the organism in old age will 
show that there is not an organ or tissue, not a function, mental 
or physical, identical at the two periods of life. Vitality, 
metaboHsm, even instinct differ. The process of senescence 
is progressive, not retrogressive, there is no reversal in the order 
of development and not a single tissue reverts to an earlier type. 

If we accept the theory of tissue cell evolution as the funda- 
mental cause of ageing, we must seek the fundamental difference 
between childhood and old age in the cells at the two periods of 
life. There are however profound differences in the organs as 
entities and in the organism as a whole. While the gross 
differences are obvious or demonstrable, we have but slight knowl- 
edge of the changes in the cell. It is probable, however, that 
some of the cell and tissue changes are not inherent but are 
caused by some change in nutrition. We have not yet discov- 
ered any change in the blood at the two periods except in the 
proportion of salts and in viscosity, although the spleen and bone 
marrow are greatly altered in advanced age. 

It would carry us beyond the scope of this work to discuss 
the kinship between chemical and physical affinities such as 
occur in simple substances like potassium for oxygen and its 
oxide for water, and the elective affinities of complex substances 
like protoplasm for the complex substances they require as 
pabulum. As a result of the fulfilment of the elective affinities 
in the organism there is going on a constant change of chemical 
combination, cyclic, imiform, imchanging in character, the like 
pabulum constituents being converted into like substances 
forming body or waste. Neither chemist, cytologist nor physiolo- 
gist has been able to explain the biochemical changes in the cell 
or the metabolic changes in the organism or demonstrate order 
in them by formula or law. Any school boy can show by sym- 



2 PHYSIOLOGICAL OLD AGE 

bols how amorphous phosphorus will combine with calcium and 
oxygen to form the tribasic phosphate of calcium, but no scien- 
tist has yet explained how this combination is brought about in 
the body since this form of phosphorus is insoluble, even in serum 
and the tricalcic phosphate, in which form it is eliminated, is 
insoluble in water and but slightly soluble in weak acids. Shall 
we say that living blood has solvent powers not possessed by any 
other solvent? How can we explain the normally increased 
retention of lime in the aged and its deposit in locations in which 
it is never foimd in early life, except in disease? We must 
assume that the early cells, which show intense greed for pabu- 
lum, will not take up more lime than the organism requires for 
healthy growth and they may take up less, causing rickets and 
similar conditions of lime deficiency, while the aged cells, in 
spite of their lessened appetite, show a greater elective affinity 
for lime. We must also assume that the blood has a greater 
affinity for lime while the metabolic processes are so altered that 
less is eliminated. Minot has shown that there is. an increase in 
protoplasm in aged cells but this alone would hardly explain the 
profound differences in cell activities at different periods of life. 
It is probable that there is a difference in the character of the 
protoplasm itself and perhaps in the nuclear constituents, 
since recent investigations have demonstrated dissimilarities in 
the chemical composition of the proteids of different cells, which 
were supposed to be identical. Greater refinement in chemical 
analysis and increased microscopic power will undoubtedly 
reveal chemical differences and organic changes which will 
clear up these problems. 

At the present moment there is but one rational assumption 
by which we can explain the progressive changes in the properties 
of cells and the tissues which they form. It is, that in the con- 
stant waste and repair of tissue the newer cells differ from the 
earlier ones, that in advanced life none of the early cells are left 
(except brain cells) , that the aged individual is in fact an entirely 
different individual from the one who was formed from the ances- 
tors of the late cells. The only connecting link between the 
child organism and the senile organism is the brain, as it is 
believed that brain cells do not regenerate themselves, that the 
old cells were all present at birth though changed in structure and 
perhaps in composition in the process of development and 



CHILDHOOD AND OLD AGE 3 

senescence. There is still the same personality, modified by 
intelligence, education and the acquisition and suppression of 
traits. Continuity of activity is maintained by retention of 
sentience in the original cells, instead of by transmission from 
generation to generation of cells as in other tissues. Like the 
old vessel which has been repeatedly repaired until not a splinter 
of the original timbers is left, the individuality and the name 
remain. 

Growth in youth depends primarily upon nutrition. The 
underfed child is also underdeveloped and no amount of over- 
feeding after the developmental period will increase the growth 
of undeveloped tissues. When well fed children are under- 
developed there is usually a dyscrasia causing impaired general 
metabolism, or there may be deficient digestion and assimilation 
or else general cell sluggishness, usually a transmitted quality. 
Whatever the cause may be the whole physical organism suffers 
but mentality is rarely impaired. In the atrophy of advanced 
life there is no uniformity in cause, extent or mode of procedure 
and like tissues may undergo different forms of degeneration in 
different parts of the body. Some organs and tissues degenerate 
earlier and more rapidly than others but with few exceptions, as 
the thymus gland and the female generative organs, there is no 
time or regularity in the order of the senile degenerations. Inac- 
tive striped muscular fiber degenerates early and undergoes 
fatty infiltration and degeneration. Active striped muscular 
fiber does not degenerate until it has reached its maximum 
growth after which the extent of degeneration depends upon the 
activity or work it is called upon to perform. If it is not exces- 
sively employed it degenerates late and then atrophies with loss 
of power proportionate to the waste of tissue. If excessively 
employed, there is loss of tonicity and a change in the character 
of the fiber, usually a fatty degeneration. When healthy tissue 
normally employed atrophies we look for a nutritional fault 
and we generally find an impaired blood-supply. In old age we 
have altered cells and supposedly altered blood. Do these aged 
cells require a different pabulum from the earlier cells? Does 
the blood in the aged carry insufficient cell nutriment or are the 
nutritional constituents so changed as to be unsuitable, or does it 
carry constituents inimical to cell life ? Transfusion of the blood 
of a young person into an old person apparently does not inhibit 



4 PHYSIOLOGICAL OLD AGE 

senile changes nor does the blood of an old individual into a 
younger one induce such changes. Further experimentation 
along these lines is necessary to determine the influence of the 
blood at different ages upon young and old cells. (W. T. Gibb 
suggested to the author the transfusion of blood from an old 
member of a family possessing hereditary longevity into a young 
member of a short lived family for the purpose of promoting 
longevity.) 

There are however other causes for senile tissue atrophy 
than the fundamental changes in the cells and the probable 
change in the blood. Connective-tissue proliferation may com- 
press tissue cells as in the liver, bands of connective tissue may 
compress blood-vessels and lessen the blood-supply as occurs in 
the spleen, or the swelling of endothelial cells may diminish the 
caliber of vessels as occurs in the vasa vasorum. 

We have still to consider the differences in vitality, metabo- 
lism and mentality in the two extremes of life. Under vital- 
ity will be included irritability or the property of responding to 
external stimuli, sentience or automatism independent of exter- 
nal stimulus, vital energy and vital resistance. (The term sen- 
tience is used here to designate the property of originating action 
independent of irritation or purpose. This would include in- 
stinctive acts and acts performed unconsciously though such are 
not usually included in this term.) While these properties are 
intimately related they will be dealt with separately. 

Irritability is pronounced in childhood and weakened in old 
age. It requires a much greater stimulus to the aged sense or- 
gans to rouse sense perception and the responses are slower than 
in earlier life, and the same applies to tissues where the senses are 
not involved. The ciliated epithelium for example is much more 
sensitive in the child and a slight irritation to the cells is followed 
by stimulation of the glands in the underlying mucous mem- 
brane. For this reason the mucus expectorated by the child is 
usually clear while the mucus expectorated by the aged individ- 
ual is usually dark from dust particles which had accumulated 
on the membrane without causing enough irritation to the cilia- 
ted epithelium to induce immediate coughing to dislodge them. 
Reflex action in the young follows initial irritation rapidly and 
instinctive acts are readily aroused upon slight stimulus while 
in the aged reflex action is slowed and weakened and instinctive 



CHILDHOOD AND OLD AGE 5 

acts are rare. Evidences of diminished irritability in the aged 
are obvious in almost every act they perform. We must remem- 
ber however that slowed responses may also be due to weakened 
mentality, a longer time being required to translate the irritation 
and determine the response. 

Sentience is active in the young, weak in the aged. The 
regulating centers in the aged are weakened and while some are 
easily disturbed others require a powerful stimulus to cause 
any change in their activity. The activity of the heat regulat- 
ing center is lessened and there is a general lower temperature 
with a normal range of about two degrees in the course of the 
day. In old age some profound influence is necessary to raise 
the temperature three degrees while in childhood with a normal 
range of a degree or less, slight influences will stimulate this center 
and cause a rapid rise of several degrees with an equally rapid 
fall to normal. The heart-regulating centers are easily disturbed 
in the aged, the respiratory center can stand but little disturb- 
ance while the vasomotor center is in a constant state of unstable 
activity. In the young functional disturbances not due to ana- 
tomic changes are quickly regulated and normal functions are 
restored without serious impairment of the organs ; aged tissues 
cannot readily accommodate themselves to functional changes and 
they quickly degenerate. Automatic activity such as respira- 
tion, heart action, peristalsis, glandular action, and voluntary 
sentient acts as deglutition without food irritation, the control of 
the sphincters, the swinging of the arms when walking, are all 
performed less energetically in old age. Early Hfe is marked 
by cellular activity; age, by cell sluggishness. 

Vital energy gradually diminishes with age except during 
the menopause, critical period of the male and the senile climac- 
teric. These periods are marked by increased mental, physical 
and metabolic activity and are followed by rapidly diminishing 
activity and energy. In youth there is a wide margin between 
normal functional activity and the limit of functional capacity. 
In advanced age the normal functional activity is diminished 
but the limit of functional capacity is lowered much faster and 
the margin between the two is gradually lessened. Activity 
is maintained by vital energy, but when carried to the limit of 
functional capacity, further activity causes exhaustion or paraly- 
sis or, in the case of blood-vessels, rupture. In the young person, 



D PHYSIOLOGICAL OLD AGE 

after running, the heart will beat faster, respiration is more 
rapid and all the organs and tissues show the effect of greatly 
accelerated circulation. The young person is forced to stop 
through muscle exhaustion, complete recuperation following rest. 
Only in case of heart disease is there any danger from heart 
exhaustion. In the aged the limit of functional capacity is 
reached before muscle exhaustion sets in and death may occur 
from heart exhaustion, respiratory paralysis or ruptiu'e of an 
atheromatous artery. This does not show diminished vital 
energy but diminished functional capacity. Diminished vital 
energy is shown by the greater effort or impulse required to 
perform acts. Acts now require a sensible effort and a conscious 
purpose which were formerly performed unconsciously or with- 
out any conscious mental or physical effort, as the regulation 
of the step when walking or the arm movement when conveying 
food to the mouth, swallowing, recalling a familiar name or 
simple relations between things, listening, seeing, crossing the 
legs, etc. The child in play runs to hide. The impulse to run 
is sudden and instantaneous and no thought is given to the 
movement of the legs in the act of running. The energy ex- 
pended is so slight as to be unnoticed unless fatigue, palpitation 
or dyspnea sets in. The old man needs a conscious impulse, 
a mental push, to start running and his thoughts are on the 
act instead of its purpose. He may walk absent mindedly as 
this requires little effort or energy but he will not run absent 
mindedly. 

Vital energy is sometimes divided into three forces, bath- 
mism or growth force, neurism or nerve-force and phrenism or 
brain force. In childhood the growth force is exerted in two 
directions, or rather with two distinct purposes, accumulation 
of tissue and differentiation of the sexes. In old age there is 
still growth of tissue but the new tissue does not fully compen- 
sate for the waste except in a few tissues. This growth force is 
now mainly exerted toward the approximation of the sexes and 
in old age they approach a neutral type. This is more pronounced 
in the virilescence of the female. In the female there is usually 
a growth of hair upon the face, while the hair on the face of the 
male becomes thin. Her voice becomes lower, his becomes 
higher in pitch. The changes in the male pelvis and in the neck 
of the femur produce a greater width between the crests of the 



CHILDHOOD AND OLD AGE 7 

ilia, and the proportion between width at the hips and length of 

the spinal column is greater in the aged man than in the younger 
male and may equal the proportion found in the female. The 
pelvis of the female infant is of the male type while the pelvis 
of the aged male approaches the female type. The thoracic 
changes are the same in both sexes and in the female the breasts 
shrivel. The changes in the lower maxilla in advanced age give 
to both the weazened face and there is often the same facial 
expression. We frequently see photographs of aged individuals 
in which the face alone gives as little indication of the sex as the 
face of the infant. The diminution in nerve-force needs no dis- 
cussion as it is evident in every act of the aged individual. The 
alteration in brain force will be taken up under mentality. 

Vital resistance or the opposition of the living organism to 
deleterious influences differs at the two periods of life. The 
yoimg are much more susceptible to infectious diseases than the 
aged and the eruptive diseases of early life rarely or never occur 
in the aged while other bacterial diseases occurring in the aged 
are milder. Various explanations have been given for this 
phenomenon, such as poor soil, lower temperature, more 
opsonins, more active leucocytosis, etc. We are again confronted 
by the question, is the blood of the aged essentially different 
from the blood of the child ? Is there any difference in the char- 
acter and activity of the cells ? 

The child can stand changes in temperature, atmospheric 
pressure, environment and mode of life better than the aged. 
Dietary changes affect the child more powerfully. While the 
child is readily affected by deleterious influences and inflam- 
matory conditions are easily produced, the young organism can 
accommodate itself to such influences ; and if disease occurs vital 
energy maintains functional activity until the organs or tissues 
involved are restored to their normal condition. In the aged 
inflammatory conditions are infrequent, when disease occurs 
the healthy senile organs cannot readily accommodate them- 
selves to functional changes in diseased organs, the functions 
are maintained with difficulty owing to diminished vital energy 
and little or no reserve energy, and tissues and their functions 
remain impaired or very slowly recover to their normal senile 
state. 

Metabolic activity is altered in old age and markedly 



8 PHYSIOLOGICAL OLD AGE 

different from metabolic activity in childhood. In childhood 
there is active destructive and constructive metabolism, the 
regeneration being in excess of the waste. Stohr says ' ' a femur 
of a three year old child contains scarcely any of the osseous 
tissue present at birth." In old age metabolic activity is les- 
sened, the anabolic processes being less active than the catabolic 
processes. Insufficient repair is found more especially in the 
higher order of tissues, the brain, marrow, spleen and muscle, 
tissues which require a plentiful supply of blood for their nutri- 
tion, while in the lower order of tissues like connective tissue, 
fat and hair there may be increased growth. Assimilation is 
altered in advanced age, many substances which in earlier life 
are retained and converted being now rejected and thrown out 
in the feces. The intestinal decomposition products are in- 
creased, the total amount of urea and uric acid eliminated is 
greatly diminished, only about half of the amount of CO2 
exhaled in early maturity is given off in senility, while the 
elimination of waste by the skin is very small. Abnormal 
fatty acids are produced and eliminated as fetid perspiration. 
Indican is always present in the urine. A smaller amount of 
food is required by the system in old age and the excess of food 
is thrown off in a lienteric diarrhea. The water content of the 
blood and tissues is diminished but increased liquid ingesta 
increases the urine output without relieving the dryness of the 
tissues or diminishing the viscosity of the blood. Salines which 
increase the fluidity of the blood are readily absorbed but are 
rapidly eliminated, while calcium salts which increase the vis- 
cosity of the blood are retained. The natural adaptation of 
tastes, wants and supply to the needs of the organism is beauti- 
fully illustrated in the aged. There is diminished activity and 
lessened need for carbohydrates and there is a distaste for 
sweets. The bile is diminished and there is a distaste for fats. 
With the falling out of the teeth there is a dislike for meat, 
9^hich must be masticated. The amoimt of hydrochloric acid in 
the stomach is diminished and the aged individual craves for 
sour and salty things while insipid foods, which are usually 
alkaline, are rejected. If, through the trickery of the cook or 
the perversion of taste, inappropriate or excessive food is taken, 
it is eliminated by the bowels unchanged or but slightly con- 
verted. The child usually vomits inappropriate food but food 



CHILDHOOD AND OLD AGE 9 

in excess is retained and stored. This is especially marked 
when sweets are taken in excess, and accounts for the chubby 
j&gures of children and young women in places where much sweets 
are used. The fancied similarity in the mentality of childhood 
and old age gives rise to the belief that senility is second child- 
hood. Only in the complete absence of intelligence of the new- 
born infant and the absolute dement is there any resemblance 
in their mentality. Even then the child performs instinctive 
acts and gives evidence of sensations as pain, hunger and dis- 
agreeable impressions which are absent in the complete dement. 
The child is guided by ancestral knowledge or instinct but such 
knowledge has virtually disappeared in old age. Whatever 
acts the aged individual performs are the result of a conscious 
purpose and reason or else of habit or irritation. Sense percep- 
tion is strong in childhood, weak in old age. This weakness is 
due partly to impairment of the sense organs, partly to weakened 
mental perception. Memory is strongly developed in the child ; 
it receives impressions, stores them and recalls them at j will as 
mental pictiires, soimds or other sensations, without apparent 
effort. In the aged only powerful impressions or those directly 
affecting the individual are retained. A sensible effort must be 
made to recall earlier impressions although ver^^ early impres- 
sions will reappear without effort or design and the aged person 
boasts of his wonderful memory. Reason is a late acquisition of 
the child and persists late in the aged. The child's mind is 
analytical ; it wants to know why, and it will take apart, destroy, 
question. The senile mind is synthetical ; it wants to know how, 
to combine, to construct and to restore. In rare cases children 
will construct and aged persons will analyze and destroy. We 
call these geniuses. In other cases individuals will perform 
remarkable constructive work at an advanced age. Here we 
will usually find all mental efforts directed into one channel 
and the particular work stands out prominently while in every 
other direction the mental faculties are deficient. There are 
differences in judgment, imagination, the ethical sense, the es- 
thetic sense, sentiment and other mental traits and characteris- 
tics between childhood and old age but these differ so widely in 
individuals of the same age that we cannot make a broad 
distinction at the two periods of life. The same applies to the 
will, although the aged generally will follow the lines of least 



lO PHYSIOLOGICAL OLD AGE 

resistance, become subjective and submit choice and resolution 
to the will of others. The child in its general conception of life 
and the world gives no thought to its somatic self ; the aged gradu- 
ally constricts his conception of life and the world until it is 
centered upon himself ; his interests are all concentrated in the 
preservation of his life. While the fundamental difference 
between the young and the old organism must be sought in some 
essential change in the character of the cell, the fundamental 
difference between childhood and old age can be summed up in 
this. Youth wants to know; age wants to be. 



PART I 
PHYSIOLOGICAL OLD AGE 



THE SENILE STATE 

We cannot deal understandingly with senile diseases if we 
do not understand the senile organism. We cannot under- 
stand the senile organism unless we study it as a physiological 
entity entirely apart from maturity. The physician must look 
upon old age as he does upon childhood. His conception of the 
child is not of an adult with undeveloped organs and tissues, nor 
does he deal with the diseases of that period of life as though 
they were diseases of maturity complicated with immature 
development. A pulse of 120 in an infant does not mean 
tachycardia nor does limited reasoning power stamp the infant 
as an idiot. These conditions are natural and normal at that 
period of life although they are unnatural, abnormal and 
pathological in maturity. We must take a similar view of 
senility. We must look upon the degenerations, the atrophies, 
hypertrophies and all the changes in form and character, that 
are due to the process of involution, as natural, normal and 
physiological. The brittleness of bone in the aged, due to the 
waste of organic matter and the proportionate excess of lime 
salts, is as natural as is the softness and elasticity of bone in 
childhood when there is still an insufficiency of lime salts. 
Senile debility is no more a pathological condition than is the 
weakness of the infant, senile contracted kidney is not Bright's 
disease although it resembles interstitial nephritis ; the hardened, 
contracted capsular ligament is not a disease of metabolism 
although the stiffness occasioned thereby and the pain on motion 
resemble rheumatism. The irregularity in the order and the 
wide variations in time and extent of the senile changes in dif- 
ferent individuals make it impossible to establish a norm or 
standard for these changes. Neither can we determine the 
extent of the senile process of involution, from the individual. 
It is not unusual to find an individual presenting the appearance 
of extreme decrepitude without marked changes in the internal 

II 



12 PHYSIOLOGICAL OLD AGE 

organs and, on the other hand, we sometimes find apparently- 
robust individuals with early signs of arteriosclerosis, cardiac 
hypertrophy, and the whole train of changes that arise from 
defective nutrition and elimination of waste, following senile 
changes in the circulatory system. Another difficulty in the 
way of determining a norm or standard of senile types is the 
impossibility of fixing averages such as serve for determining 
standards in maturity. In maturity the anatomical condition 
and the physiological function generally bear a definite relation 
to each other. In advanced age we frequently find degenerative 
changes without marked noticeable change in function; indeed, 
we may find the changes due to age occur in early maturity 
while functional activity may increase. The brain reaches its 
maximum weight about the thirtieth year after which there is 
a gradual loss of weight, yet the maximum mental capacity is 
generally reached about the fiftieth year or later. The lungs 
reach the maximum respiratory capacity about the thirtieth 
year, and a diminution from this maximum capacity has been 
demonstrated before the fortieth year while the earliest symp- 
tom of impaired respiration, dyspnea, does not usually manifest 
itself before the middle of the sixth decade of life. Since we 
are unable under these circumstances to establish a standard 
based upon either age, or extent or character of morphological 
changes it will be necessary to use extreme types for the purpose 
of description. We must remember, however, that even such 
types may be normally exceeded, while under some circumstances 
slight deviations from the norm of maturity may be patho- 
logical. We also find occasionally a pathological condition which 
has existed for so long a time that it has become normal to the 
individual. Such cases will receive no further consideration. 

The obvious characteristics of senility are evidenced in the 
appearance, attitude, gait, mentality and the tout ensemble of 
mental and physical decay. The appearance of the senile 
individual is repellent both to the esthetic sense and to the 
sense of independence, that sense or mental attitude that the 
human race holds toward the self-reliant and self-dependent. 
It is not within the scope of this work to discuss the psychonomy 
of the emotions; this much is however certain: While the 
dependence of the child arouses sympathy, in the aged the 
repugnance aroused by the disagreeable facial aspect and the 



THE SENILE STATE I3 

idea of economic worthlessness destroys the sympathy we 
bestow upon the child and instills a spirit of irritability if not 
positive enmity against the helplessness of the aged. We 
find herein one of the causes for the general neglect of the aged, 
where this spirit is not overcome by a spirit of reverence. The 
mental depression and the lack of interest in things beyond the 
ego of the aged individual contribute to the general feeling of 
repulsion and all these factors accentuate the disagreeable 
tout ensemble of old age. The countenance is either expres- 
sionless, indicating mental weakness, or there is an apathetic 
moroseness indicative of helpless resignation, or else there is 
the anxious look associated with a haunting fear. The skin is 
dry, lusterless, darker than in maturity, often pigmented, loose 
and thin, showing varicosed veins and tortuous arteries under- 
neath. In some localities the skin lies in folds producing coarse 
and fine wrinkles. This is due partly to the looseness of the 
skin itself and partly to the waste of muscular fibers and fat 
tissue. The hair is thin, gray or white, there is often baldness, 
sometimes there is an excessive growth of hair in unusual places 
as in the nose, ears, eyebrows, and on the upper lip of women. 
The nails become brittle and are frequently cracked, they 
generally show neglect, the ends being broken or worn off. 
Owing to the impaired circulation and defective oxygenation of 
the blood there are usually cyanosed lips, pale ears and areas of 
passive hyperemia over the malars and at the tip of the nose. 
The waste of the muscles is determined by their activity. In 
actors and public speakers who make frequent use of the facial 
muscles in giving expression, these muscles waste in bulk, they 
present tense borders leaving the muscles in sharp outline. In 
these cases the muscle texture remains unchanged. Where the 
facial muscles have not been much employed they become 
subjected to fatty infiltration, the muscles waste late, they leave 
no sharp borders and they are soft and flabby. This condition 
is well seen in the dull ignorant peasant in whom the masseters 
show the waste due to activity while other facial muscles 
present the changes referred to. In this class too do we find the 
skin much darker owing to exposure and rough treatment. 

A marked senile characteristic which itself gives the im- 
pression of lack of energy is the atrophy of the lower maxilla, 
producing the so-called weak chin of the physiognomists. This 



14 PHYSIOLOGICAL OLD AGE 

atrophy includes loss of the teeth and waste of the alveolar 
process, a more obtuse angle of the jaw and changes in the 
articular surfaces, causing changes in the anatomical relations of 
the bones of the face. The eyes are generally lusterless and pre- 
sent a gray ring around the cornea, the arcus senilis. There is 
frequently a ptosis of the upper lids and occasionally a mild 
ectropion. The attitude of age is well described as a slouch. 
The stature is diminished through compression of the interver- 
tebral discs, exaggeration of the spinal curvatures, flattening of 
the pelvis, depression of the neck of the femur and generally 
broken-down arches. There is also an apparent decrease in 
stature owing to the droop of the head and the bent knees, the 
former being due to weakness and waste of muscle, the latter 
being caused by the effort of the individual to maintain equilib- 
rium. A psychic cause for this senile slouch will be described 
under senile debility. The senile gait, the "abasia senescent- 
ium" of Petrens, is a halting walk with slow, short, uncertain 
steps. Naunyn calls it a neurosis due to impaired coordination. 
I am inclined to ascribe this gait to a weakening of the subcon- 
scious control by which we regulate our walk, the weakness of 
the muscles, slowed motor impulses and the stiffening of the 
joints in senility. In addition there is usually some pedal defect 
such as broken-down arches, hammer toes, bunions, etc. 

The most profound changes occur in the functions of the 
brain. The many complex factors embraced in the term 
mentality, the uncertainty of their interrelations and our ignor- 
ance of the mode of action of the brain preclude any lengthy 
discussion of this subject. The senile changes in mentality are 
found in temperament, emotions, will, sensations and intellect. 
The most prominent mental characteristic in old age is an over- 
whelming interest in self, a selfishness which gradually subor- 
dinates every other interest in life to the welfare of the individual. 
Notwithstanding all the optimistic platitudes of philosophers 
from the days of Cicero to Metchnikoff, notwithstanding the 
inbred resignation of the fatalists, the ready submission to the 
inevitable of the materialists, notwithstanding the promise of 
heaven, bliss and light and life everlasting, made by theologians 
of all ages, man looks forward to death with dread and indigna- 
tion. And the nearer he approaches the abyss beyond which, 
he is told, lies eternal life, the greater his dread, the more pro- 



THE SENILE STATE 1 5 

found is his sense of impotence, the more depressing is his 
resignation. In the healthy mind of maturity thoughts of death, 
when they arise, are set aside, for future reference as it were, 
unless some circumstance momentarily forces attention to 
death. When, however, the infirmities of age bring such 
thoughts persistently and with ever-increasing intensity to the 
individual, life assumes a value incomprehensible to the younger 
mind. With increasing infirmities and the realization that the 
span of life is rapidly nearing its end, the desire to Hve becomes 
the all-absorbing thought. In this intense desire to live we find 
the basis of the selfishness of the aged. It is also the cause of 
his suspiciousness, his egoism and temperamental changes. 
There are contributing causes which may in some instances be 
more potent than the causes just stated. The fear of leaving a 
family unprovided for, the fear of becoming a burden to the 
family, or friends, or the State, may produce a moroseness 
and depression which would change the temperament of the 
individual. Likewise would the irritability caused by discom- 
forts produce the same effect. These changes affect the emotions 
and, as the reasoning power diminishes, its ability to control 
the emotions wanes. 

In old age a stubborn unreasoning perverseness often takes 
the place of a reasonable strong will. Of the intellectual 
faculties memory is usually the first to show impairment, names 
and numbers being quickly forgotten. Recent events unless 
directly affecting the individual are not firmly impressed upon 
the mind and are soon forgotten, while early events are readily 
recalled. In those accustomed to employ the reasoning faculty, 
this faculty generally remains unimpaired so far as the quality 
of the work is concerned, but greater mental effort is required 
and brain fatigue sets in m.ore rapidly. In some individuals 
all of the intellectual faculties become uniformly weakened, 
producing a progressive senile dementia. There is a marked 
change in mentality during the senile climacteric which will be 
described further on. 

In this brief review of the obvious changes that occur as a 
result of ageing, special stress has been laid upon the mental 
changes, as they are often the first indications that the period 
of decline has begun. Lessened interest in the events of the 
day, a tendency to sleep after some mental work, greater 



1 6 PHYSIOLOGICAL OLD AGE 

difficulty in getting ideas or some particular word to express 
ideas, forgetfulness, all point to senile changes in the brain. 

The subjective indications of advancing age do not corre- 
spond with the objective manifestations. In many cases of men 
the first change which attracts the attention of the individual is 
lessened sexual power without diminished desire. Occasionally 
the desire first wanes and in such cases there arises often sexual 
perversion. In many cases the individual complains of pains 
and aches in the muscles and joints which he ascribes to rheuma- 
tism, or of shortness of breath which he says is asthma, or of a 
desire to sleep after ordinary mental or physical work and this 
he calls malaria. Some men will take the first gray hair as an 
indication of ageing and this is the only obvious manifestation 
which the individual will notice before others. Many persons 
will deny any feeling of age, even when such pronounced 
symptoms as dyspnea, palpitation of the heart, pains and aches 
in muscles and joints, and diminished capacity for all kinds of 
work are present. 

While nearly all that has been said applies to women as well 
as to men, there are some differences in both the objective and 
subjective manifestations between the sexes. Many women 
begin to lose energy and power immediately after the meno- 
pause, and this may be looked upon as the earliest of the sub- 
jective manifestations of ageing. Objectively we find a growth 
of hair upon the upper lip, a waste of the muscles of the neck, 
deposit of adipose tissue upon the abdomen. The senile kypho- 
sis is not as marked in women as in men. This is due partly to 
the effort to maintain an erect bearing and to present a pleasing 
appearance, partly to the support given to the back by corsets 
and stays, and partly to the slighter downward pressure exerted 
upon the spinal column by wearing the dresses suspended from 
the hips instead of from the shoulders. The mental changes in 
the female generally include all the intellectual faculties and 
proceed to the extent of complete dementia far more often than 
in the male. 

The obvious manifestations of senility appear later in the 
female, for the reason that she makes an effort to remain at- 
tractive, the psychic factor involved in the production of the 
senile slouch in the male being overcome by her vanity, there 
is absent the senile kyphosis, the marked waste of the facial 



THE SENILE STATE 1 7 

muscles, and often the wrinkles generally seen in the male. 
Women being more impressionable than men, they are more 
amenable to religious teachings, they become more readily re- 
signed to the inevitable through their faith and hope of eternal 
life hereafter, and being more cheerful they do not present the 
disagreeable, gloomy appearance of aged m.en. This as well as 
their sex brings to them the sympathy denied to men. 

Our conception of old age must be based upon the harmoniza- 
tion of the objective manifestations, of the subjective mani- 
festations and the organic (physical and mental) changes so 
far as we can determine them. In considering the objective 
symptoms we must exclude the slouch due to laziness, the care- 
worn expression due to worry, the waste of muscle from disease 
and insufficient food, the roughened skin due to exposure or 
improper treatment, the kyphosis due to certain vocations as well 
as to disease, the peculiar gait of various nervous disorders and 
the mental weakness of cerebral disease. The subjective symp- 
toms may be due to various diseases. Of the organic changes 
only one has been found to be invariably due to ageing. This is 
the progressive increase of interstitial fibers between the pyramids 
of the kidneys, first described by Doctor Jos. Walsh of Phila- 
delphia. Every other senile change in the organism may also 
be found as a pathological process in maturity, and it is often 
difficult to determine whether the change is due to ageing or to 
disease. The difficulty is increased by the fact that changes 
due to ageing have been demonstrated in early maturity yet give 
no manifestations, objective or subjective, until two or three 
decades later. Diminution in respiratory capacity begins 
about the end of the fourth decade yet difficult respiration due 
to the atrophy of the lungs may not manifest itself until the 
sixth decade or later. The brain begins to lose in weight during 
the fourth decade, sclerotic and atheromatous changes in the 
blood-vessels without apparent cause or complicating disease 
have been observed in the third decade, while cardiac hyper- 
trophy has been found in athletes before the third decade. The 
popular conception of old age is based upon the appearance of 
the individual. It is not unusual, however, to find apparently 
decrepit individuals regain strength, mental activity, cheerful- 
ness and a more buoyant spirit as well as a more youthful 
appearance when freed from care and the necessity to work. 



1 8 PHYSIOLOGICAL OLD AGE 

This is a common observation in inmates of homes for the aged, 
shortly after their admission. A conception of old age based 
upon the subjective manifestations may be equally fallacious, 
as these may be symptoms of true pathological processes, or 
due to temporary psychic influences. Neither can we base 
our conception of old age upon the organic changes due to ageing, 
as these may appear in early maturity. The term old age 
should be applied only to such cases as present obvious mani- 
festations or marked subjective symptoms with the progressive 
organic changes which are due to ageing. The term senility is 
usually applied to a more advanced old age. It implies pro- 
nounced senile changes with the accompanying objective and 
subjective manifestations, and covers the period from the time 
when the mental and physical impairment begins to incapaci- 
tate the individual, to the complete decrepitude that ends in 
physiological death. It corresponds to the postclimacteric 
stage of the period of decline. 

During this climacteric there is a readjustment in the 
relations between the functions, and changes in the organs 
necessary to carry out the new functional relations. There is 
no regularity in the order or rapidity with which organs and 
tissues undergo senile involution, and consequently we find 
vast differences in the mental and physical condition of indi- 
viduals of the same age. There is a time, generally about the 
latter part of the seventh or eighth decade, when profound 
changes occur both m.entally and physically. This is the 
transitional period between old age and senility and corresponds 
to the critical period that occurs during the period of develop- 
ment called puberty and the critical period during the period of 
maturity called the menopause in the female. I have called 
this critical period in the period of decline, the senile climacteric. 
Some at that age show little physical impairment, while others 
are decrepit. Usually there is mental depression with some 
impairment of the faculties, lessened activity, and degeneration 
of some organs and tissues, due to arteriosclerosis or primary 
degeneration, while other organs and tissues show little change. 
In those who have lived slow, rational lives, the senile changes 
proceed slowly, gradually, and harmoniously. Most individuals 
are so situated or so constituted that greater stress is put upon 
some organs and tissues than upon others, and these degenerate 



THE SENILE STATE IQ 

faster than the others. As a result of the unequal rate of degen- 
eration in the organs, the harmonious interaction of functions 
is disturbed, and we have pathological conditions, giving ob- 
jective and subjective manifestations of disease. In nature's 
effort to effect a readjustment of the fimctions during the senile 
climacteric those organs which have degenerated slowly now 
degenerate rapidly, while the degenerative changes in those 
organs which have been most involved are retarded. 

Among the earliest of the obvious changes that occur in the 
senile climacteric is a change in the mentality of the individual. 
There is a change in mentality at the beginning of the period of 
decline, due partly to the recognition by the individual that 
he is entering upon the closing period of life, and partly to weak- 
ening of the intellectual faculties. A more profound change 
occurs during the senile climacteric. There are now periods of 
emotional exaltation followed by depression. At times there is 
mental confusion with delusions which are soon forgotten, 
flashes of former mental vigor during which brilliant work may 
be done but if such work is prolonged beyond a few minutes or 
hours the character of the work deteriorates and it becomes 
confused and finally it becomes unintelligible, memory is dulled 
and cannot be stimulated by any process of mnemonics. There 
are lucid intervals diiring which there is no evidence of mental 
deterioration except perhaps weakened memory. Gradually, 
however, this period merges into the postclimacteric period, the 
periods of exaltation become less pronounced and less frequent, 
and the depression gives way to apathy, the reasoning power 
wanes rapidly, the intense biophilism, or love of life, that marks 
the early stage of senility, passes away. Interest in aU direc- 
tions is diminished, the individual becomes garrulous, seeks the 
association of children in preference to adults, and falls into 
childish ways. Occasionally there is a recrudescence of sexual 
desire, to gratify which he may attempt rape upon little girls. 
Such crimes do not arise from depravity, but through weakened 
mentality involving a weakened moral sense, inability to 
realize the nature of the act or its consequences, a loss of control 
over conduct, and an irrepressible sexual fury. Such acts 
occur almost invariably during the senile climacteric. 

Especially noticeable during this period is a change in facial 
expression, corresponding with the mental change. At the same 



20 PHYSIOLOGICAi: OLD AGE 

time the strength diminishes, and the individual is forced to 
use a cane; in some cases this is accompanied by senile tremor, 
rarely by a pseudoosteitis deformans. Owing to the rapid 
degeneration of those organs which had shown but little senile 
change before, these organs are peculiarly liable to disease, hence 
we find most deaths in the early part and middle of the eighth 
decade resulting from diseases in organs that were apparently 
healthy before the final illness. While these organs may have 
degenerated before the climacteric, the process had proceeded so 
slowly and gradually as to give no subjective or objective 
symptoms. This is especially noticeable in the heart. If the 
heart has not been subjected to excessive strain before this time, 
the cardiac hypertrophy kept pace with the demands made 
upon the organ. Now, however, it has reached the limit of 
its ability to compensate for the impaired circulation due to 
arteriosclerosis and valve defects, and it begins to dilate. In a 
series of forty-five deaths between the ages of seventy and eighty 
years, occurring in a fraternal order, there were ten deaths from 
various forms of heart disease and five from arteriosclerosis. 

Other changes that may be noted at this time are the rapid 
whitening of the hair, where it had thus far retained its color, 
while the falling out of hair ceases. The skin becomes thin, 
loose, and transparent; in some cases there is a growth of warts 
or other excrescences. The dyspnea of senile emphysema fre- 
quently disappears as the impaired heart sends less blood to the 
lungs, thus reestablishing harmonious relations between the 
two organs. A similar readjustment in the functional relations 
of allied organs is often found in the activities of the stomach 
and intestines. The loss of teeth necessitating a change in 
diet, and change in the functional activity of the digestive organs, 
possibly, too, a change in the taste for certain kinds of food, 
cause a change in the nutrition of the aged individual. Insipid 
articles of food become distasteful. Such substances are usually 
alkaline in reaction and are indigestible in the stomach owing 
to the subacidity of the gastric juice. There is generally a dis- 
like for fat and at the same time the secretion of bile is 
diminished. Underdone meat, a frequent source of constipa- 
tion, is rejected partly on account of the inability to chew 
it and partly on account of distaste. Acids and sharp, spiced 
condiments are relished, and these aid digestion and are of 



ANATOMICAL CHANGES IN OLD AGE 21 

service in the senile constipation. On account of diminished 
appetite there are longer intervals between meals, and this pre- 
vents overloading the stomach and the addition of food to 
undigested food already in the stomach. At this time the aged 
individual demands food in the form of mush or liquid, and 
softer stools are produced, lessening the danger of fecal im- 
paction and favoring more rapid elimination. 

I should ascribe the relief frequently obtained in the post- 
climacteric period from the trouble of senile constipation of the 
earlier period to this change in diet and digestion and not to the 
cathartics that may have been given for years before. The 
senile climacteric may last a few months or even a year or more. 
Its inception and completion are gradual, it presents no specific 
manifestation as occurs in the female in puberty and the 
menopause, nor are the differences in the organism between the 
preclimacteric and the postclimacteric periods as marked as 
between the prenubile and postnubile stages of the period of 
development or the preclimacteric and postclimacteric stages of 
maturity. After the senile climacteric has passed, there is a 
uniform decadence of mind and body. The intellectual faculties 
become gradually weaker, but rarely reach the stage of complete 
dementia. Muscle tonicity and nervous activity gradually 
lessen, breathing becomes slower and more shallow, heart action 
becomes weak, assimilation becomes more difficult, and elimina- 
tion is diminished. If no one organ is excessively strained or 
irritated, the functions maintain their harmonious relations to 
each other, gradually weakening, until complete cessation in 
physiological death. 

ANATOMICAL CHANGES IN OLD AGE 

The anatomical changes due to old age are of the most 
diverse character, they are neither uniform nor regular nor do 
we always find like changes in similar tissues in different indi- 
viduals, until late in life, when changes become uniform and we 
find like organs subjected to like changes. 

The changes in bone include waste of organic matter with 
consequent proportionate increase in inorganic matter whereby 
bones become more brittle, they fracture more readily and 
repair is more difficult ; there is osteoporosis of the short bones, 
of the epiphyses of long bones and of the diploe of flat bones; 



22 PHYSIOLOGICAL OLD AGE 

late in life there is a waste or resorption of the entire bone sub- 
stance. Irregular waste and pressure cause changes in the shape 
of bones. Marked changes are found in the skull, spinal 
column, thorax, pelvis, femurs and feet. 

Cranial bones become thin, local waste occasionally proceed- 
ing to the extent of complete perforation, the edges of the opening 
being raised through the increased osteoporosis of the diploe over 
the wasted area, and the sutures become obliterated. The most 
pronounced osseous waste is found in the lower maxilla. Owing 
to the loss of the teeth and the consequent absorption of the 
alveolar process, the chin must be raised higher in the act of 
closing the mouth, the condyles are consequently brought 
further down and back, the rami become oblique and the angles 
of the jaw become obtuse. There is at the same time a general 
atrophy of the bone, the chin becomes more pointed, the mental 
foramen is smaller and on account of the waste of the body of 
the bone it is found near the alveolar border. These changes 
in the lower maxilla produce the weazened face of old age. The 
changes in the spinal column are due mainly to changes in the 
intervertebral discs and will be described under cartilage changes, 
and under the same heading will be found the thoracic changes, 
The changes in the pelvis are waste, osteoporosis and change 
in shape, the last being the most noticeable. Owing to the 
constant downward pressure upon the sacrum this bone is pushed 
back, the angle of the sacro-lumbar artictdation becomes more 
acute, there is anchylosis of the sacrum and coccyx and the 
sacro-iliac relations become altered, the ilia being forced back- 
ward to accommodate themselves to the changed position of the 
sacrum. Between this downward and backward pressiure of the 
sacrum and the upward pressure exerted by the femurs the whole 
pelvis becomes vertically compressed and horizontally expanded. 
The width of the pelvis is apparently increased still more through 
waste of the glutei muscles and through changes in the neck of 
the femur which bring the greater trochanter higher and further 
out. The ilia become thin, the pubes undergoes osteporosis and 
late in life wastes, the acetabtdi become shallow and larger 
through the waste of the surrounding bone. The principal 
change in the femur is found in the relation between neck and 
shaft. In maturity they form an angle of about 145 degrees, 
but in old age the neck becomes depressed until the angle 



n 




Section of the Head of the Thigh Bone of a Man of Thirty-seven Years. 
(From Minot's "Problems of Age, Growth and Death." G. P. Putnam's Sons, 
New York and London.) 



Section of the Head of the Thigh Bone of a Woman of Eighty-two Years. 
Shows also depression of head of femur. (From Minot's "Problems of Age, 
Growth and Death." G. P. Putnam's Sons, New York and London ) 



ANATOMICAL CHANGES IN OLD AGE 23 

formed approaches a right angle. Osteoporosis destroys the 
arrangement of the cancellous structure of the neck, the bone 
being thereby weakened, thus accounting for the frequency of 
fracture of the neck of the femur in old age. Other changes in 
the femur are such as occur in all long bones. Broken-down 
arches of the feet are found generally in the aged. It may be 
questioned whether this is a physiological or a pathological 
condition in old age. It is due to the downward pressure upon 
the feet and weakness of the tendons, and frequently to improper 
shoes. 

The cartilage changes are waste, ossification, calcification and 
formation of fibrous tissue. The articular cartilages become 
dry, then thin and through attrition they become fibrillated and 
waste. In the larynx the thyroid, cricoid and arytenoid carti- 
lages ossify while the epiglottis becomes fibrous. The carti- 
laginous rings of the trachea sometimes ossify and occasionally 
the bronchial cartilages suffer likewise. In the sternum com- 
plete bony union of the parts of the gladiolus takes place before 
the thirty-fifth year. About the same time the cartilage be- 
tween the manubrium and the gladiolus begins to calcify, the 
ensif orm cartilage ossifies and later ossification takes place in the 
costal cartilages. In old age all these tissues become anchylosed 
forming with the ribs and spinal column a rigid thorax. The in- 
tervertebral discs begin to calcify about the fiftieth year. Owing 
to the constant downward pressure upon the spinal column 
when the body is erect these discs become compressed. In 
maturity the discs are elastic and when the pressure is relieved 
(as in the recumbent position) the discs resume their natural 
shape. This accounts for the greater stature in the morning 
than at night. This expansibility of the discs is lost when they 
calcify and the diminished stature becomes permanent. The 
pressure is greatest where the discs are thinnest, anteriorly in 
the dorsal region and posteriorly in the cervical and lumbar 
regions. The compression is not so great in the cervical region 
and the lumbar discs are thicker and more uniform. The 
greater compression of the anterior portion of the dorsal discs 
spreads the posterior borders and causes the increased curva- 
ture of the spine in that region in old age. It also produces an 
approximation of the facets whereby a more acute articular 
angle with the ribs is produced. The ribs in order to accommo- 



24 PHYSIOLOGICAL OLD AGE 

date themselves to the changed articular relations in the back 
and the ossified costal cartilages in front become flattened at 
the sides. These changes, together with the lessened resilience 
of the ribs owing to the waste of organic matter, occasion the 
senile chest which resembles the rachitic chest, being longer in 
front, shorter in the back and flattened at the sides. 

The changes in the ligaments are hardening and contraction. 
The ligamentum nuchse is sometimes lengthened but never 
flaccid. The most marked changes are found in the capsular 
ligaments in which the hardening and contraction may proceed 
to the extent of complete immobilization of a joint. Stiff joints 
from this cause are quite frequent but are often diagnosed as 
rheumatic arthritis. The changes in muscle are atrophy, fatty 
infiltration, fatty degeneration, stretching and in the case of the 
heart, hypertrophy. 

In active muscles there is primary atrophy through the waste 
occasioned by muscular action, the waste not being fully repaired. 
In inactive muscles there is a secondary atrophy following fatty 
infiltration, the fat cells displacing muscle fiber and appropri- 
ating nutrition of the muscles. The difference between the atro- 
phic and the fatty changes is seen in comparing the two biceps 
of the aged artisan, the right being smaller but maintaining 
its muscle consistency and strength in proportion to its mass, 
while the left is flabby, there is but little waste and the loss of 
strength is greater than in the right. The differences in the 
changes in the facial muscles between the actor and the dull 
peasant have been referred to. The greatest waste occurs in 
the intercostals, these being, after the heart, the most actively 
employed muscles of the body. The heart muscle hypertrophies, 
rarely atrophies. Fatty infiltration and fatty degeneration of 
the heart which are sometimes found in the heart of the aged 
are pathological and due to impaired nutrition. We sometimes 
find a pseudohypertrophy of the muscles due to the prolifera- 
tion of connective-tissue fibers through the muscle fibers. This 
occurs in the walls of the bladder whereby bands are formed with 
pouches and pockets between them. 

The changes in the skin are of the most varied character 
including atrophy, localized and more extensive areas of hyper- 
trophy, anemia, congestion, pigmentation and changes in the 
character of the cells of the various tissues forming the skin. 




Ossification of subscapalaris tendon. 

M. D. 



Waste of bursa. 

New York.) 



(Courtesy of S. Epstein, 




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ANATOMICAL CHANGES IN OLD AGE 25 

There is generally waste of the subcutaneous fat, atrophy of 
the derma, the areolar tissue becomes fibrillated, the connective 
tissue becomes loose and separates, the glands waste and there 
is waste of the elastic fibers. As a result of these changes the 
skin becomes dr}^ lusterless, loose and flabby. In some locali- 
ties the sweat glands exhibit greater activity and the character 
of the secretion is changed. Pigment is deposited in the rete 
Malpighii, sometimes locaHzed as ecchymotic spots on the hands, 
neck and other exposed portions of the body, sometimes covering 
more extensive areas. In some localities there may be extensive 
brown patches due to passive congestion. Folds and wrinkles 
are caused by waste of fat and elastic fibers. The h^^pertrophies 
take the form either of thickened epidermis on the hands or 
feet or there ma}^ be hard or soft warts. There is loss of pig- 
ment in the hair, the hair bulbs generally atrophy causing falling 
out of the hair although there is often an abnormal growth in 
imusual places as in the nostrils, ears, etc. The nails become 
dry and brittle. The skin is generally cold and where not pig- 
mented it is pale, on account of the deficient circulation, or it 
presents areas of local passive h3"peremia. There is generally 
degeneration of the nerve terminals producing various sensory 
disturbances. 

The most important senile changes occur in the circulatory 
system. The hypertrophy of the heart is usually the earHest 
of these changes but the changes in the blood-vessels produce the 
most profound disturbances in the organism. The earliest change 
in the arteries is a hyperplasia of the connective tissue of the 
intima with consequent stiffening of the vessel, thickening of 
the inner coat and diminution of the caliber. This is accom- 
panied or followed by a waste of the elastic fibers whereby the 
elasticity of the artery is diminished. These changes in the 
vaso vasorum cause diminished circulation through them, in- 
terfering with the nutrition of the larger vessels and conse- 
quently these vessels degenerate. The inner coat becomes soft, 
fat deposits and we find atheromatous foci or plaques on the 
surface of the inner coat. Later results of defective nutrition 
are : waste of muscle fibers, hardening of the outer coat, calcareous 
deposits in the inner and middle coats, and finally calcification 
of the entire vessel. Before calcification the vessel is harder 
than normal and tortuous. After partial calcification the vessel 



26 PHYSIOLOGICAL OLD AGE 

feels beady but the pulse can be felt. In diffuse calcification 
the vessel is rigid and in extreme cases the pulse is absent, the 
vessel feeling like a hardened tendon. Such extreme cases are, 
however, rare. Advanced arteriosclerosis is most frequently 
found in the aorta, the cerebral vessels, thecoronaries, the radials, 
vertebrals, carotids, splenic, brachial, iliac and femoral arteries. 
The aorta is almost invariably affected, being dilated and show- 
ing extensive fatty and calcareous plates in the ascending and 
often in the transverse portions. The diminution of caliber 
in the smaller vessels may extend to complete obliteration of 
the lumen, thereby depriving the parts beyond of nutrition. 
This causes gangrene or other destruction of tissue. The earliest 
change in the heart is hypertrophy and this may begin during 
the period of development. Cardiac hypertrophy which is the 
normal condition of the heart of the aged cannot be called a 
senile degeneration, as the same causes that prevail in old age 
prevail in the earlier periods of life. Whatever tends to make 
the heart act faster or more powerfully tends to cause it to hyper- 
trophy. Excessive activity, elevation of temperature, nervous 
influences, will cause hypertrophy, as well as the greater force 
required to send the blood through the contracted, inexpansible 
blood-vessels. The heart in the aged is heavier and larger than 
in maturity, the average weight in the male being 1 1 ounces and 
in the female 91/2 ounces (Loomis). The cavities are increased, 
the proportionate capacity remaining unchanged. The left 
ventricular wall is much thicker than the walls of the other 
cavities, being thickest just below the level of the mitral valve 
and diminishing rapidly toward the apex. The valves are thick- 
ened and the valvular orifices are enlarged. The aortic opening is 
larger than the others and aortic insufficiency is the rule in old 
age. The endocardium undergoes the same changes that are 
found in the inner coat of the arteries including fatty plaques and 
calcareous deposits. The more pronounced changes resembling 
chronic endocarditis will be described under senile endocarditis. 
Myocarditis, the fatty degenerations, and atrophy of the heart 
will be treated as diseases. The changes in the veins are similar 
to the early changes in the arteries. The inner coat becomes 
soft and there is loss of the elastic and muscle fibers of the other 
coats. The veins rarely become hard, but the waste of the 
elastic fibers allows a dilatation of the vessels. They are often 



ANATOMICAL CHANGES IN OLD AGE 27 

tortuous and occasionally we can feel a venous pulsation, espe- 
cially in the neck. The veins are usually filled to excess with 
a slow-flowing current of blood, this condition being known as 
venosity. The principal pulmonary change is atrophy of the 
lung. There is diminution in size and weight, the lung is com- 
pressed through the changes in the thorax, its expansibility is 
diminished, the bronchioles show extensive dust deposits partially 
occluding their lumen, producing pneumokoniosis, the septa be- 
tween the alveolae waste and the air vesicles consequently coalesce, 
producing senile emphysema. The senile lung is grayish with 
black spots and lines over its surface and throughout its mass, 
and dilated or ruptured air vesicles are clearly seen on section 
as minute cavities. The lung has a more elastic feel than in 
matiuity but with diminished crepitation. In advanced senility 
when the atrophy is very marked they lie close to the vertebral 
column, their surface is uneven, the upper lobe of the left lung 
sinks and falls forward of the lower lobe, so that the upper lobe 
is in front and the lower one is behind it, while in the right lung 
the middle lobe sinks and falls in front of the lower one. We 
sometimes find the lower lobe of the right lung overlapping the 
upper one posteriorly. The respiratory capacity diminishes. 
The decrease has been demonstrated in the early part of the fourth 
decade, but not until it is far advanced are marked objective or 
subjective manifestations produced. The loss, which is about 
1/2 per cent, of the total capacity per annum at thirty-five, 
rises to i per cent, or more about sixty. The trachea and the 
upper part of the bronchi become rigid and frequently contain 
calcareous incrustations, the bronchioles have their calibers 
diminished and occasionally the lumen is entirely closed. The 
pleura becomes thin, dry, lusterless, opaque, the layers are 
generally adherent to each other and the outer layer is adherent 
to the chest wall. The changes in the digestive tract are found 
throughout its entire length. The teeth fall out, the alveolar 
process of the lower maxilla wastes, the salivary glands atrophy 
and their secretions are diminished but not altered in composi- 
tion. The stomach becomes dilated through atony and waste 
of the muscular fibers, there is an atrophy of the glands, the 
mucous membrane becomes thin and pale, the amount of hy- 
drochloric acid is diminished and there is probably some change 
in the character of the peptic secretions. In the intestines there 



28 PHYSIOLOGICAL OLD AGE 

is a waste of the muscle fibers and diminished secretions. The 
small intestines become very thin, the large intestines are gener- 
ally dilated, the dilatation about the sigmoid flexure sometimes 
forming a pouch or sack, of two or three times its normal diam- 
eter. Owing to the impaired circulation hemorrhoids are 
frequently present. Atheroma of the nutrient vessels causes 
atrophy of the villi, and waste of muscle fibers causes the folds 
of the valvulse conniventes to be smoothed out. 

The liver is contracted and harder than in maturity, the cells 
are smaller, there is an increase of connective tissue and owing 
to lessened nutrition the organ is paler than in maturity. In 
extreme old age its weight may sink to 800 grams or less. If, 
however, there is impeded circulation or weakened heart action 
there will be engorgement. The surface becomes granular and 
the capsule becomes cloudy, thick and closely adherent to the 
surface. The gall-bladder becomes thickened and usually 
adheres to the adjacent portion of the liver. The duct is thick- 
ened and its caliber is diminished. The bile is thicker, more 
viscid than in maturity and contains a larger proportion of 
cholestrin. Gall stones are frequently found. The spleen is 
reduced in size, it becomes firm, the trabeculse compress the 
blood-vessels causing them to atrophy and in extreme cases the 
whole organ is a mass of connective-tissue fibers enmeshing 
small portions of spleen substance. The relative loss of weight 
of the spleen is greater than that of any other organ, the spleen 
in old age weighing less than half as much as in maturity. The 
pancreas atrophies, there is proliferation with hardening of the 
connective tissue compressing the vesicles and lobules, the canal 
of _Wirsung becomes hard and its caliber diminished. Occasion- 
ally the organ undergoes fatty degeneration without diminution 
in size. Its texture which is in maturity rather soft becomes 
harder, of the consistency of softened wax. The kidneys un- 
dergo atrophic, sclerotic and other degenerative changes which 
are so like the pathological: changes found in interstitial nephritis 
that it is often impossible to distinguish between them at post- 
mortem examinations. The recent discovery of a progressive 
increase of connective-tissue fibers between the apex of the 
pyramids — the increase continuing from birth to death in 
old age — is as far as known the only histological manifestation 
of ageing which does not appear as a pathological condition. 




Colomc Pouch. (From Tyson and Fussell's ''Practice of Medicine.'') Pho- 
tograph of colonic dilatation in a young man. Used here to illustrate the senile 
colonic pouch, which it resembles. 




Pancreas Showing Increase of Fibrous Tissue. 
Chronic Interstitial Pancreatitis. (From Coplin's 
"Manual of Pathology.") .4, .4. Areas of hemorrhage. 
B, B Immature gland cells (bodies of Langerhans). C. 
Gland acinus. D, D, D, D, D. Fibrous tissue; the areas 
of rhexis {A, A) are also in the fibrous tissue. 



ANATOMICAL CHANGES IN OLD AGE 29 

The kidney in old age has a lobulated appearance, it is granu- 
lar, pale, and hard, the glomeruli, loops and convoluted tubes 
atrophy and become sclerosed. The connective tissue forms 
bands which compress the parenchyma. The capsule becomes 
thick and adheres closely to the surface. The ureters lose their 
elasticity through waste of muscular fibers and the tubes become 
dilated. The inner coat becomes thickened but the caliber is 
increased and late in life the ureters become stiff fibrous tubes. 
The senile changes in the bladder begin with a waste of muscular 
fibers and a proliferation of connective tissue. The waste of 
muscle permits a dilatation of the walls of the bladder while 
the connective tissue forms bands in the walls producing con- 
strictions with pockets between them. The sphincter atrophies 
permitting dribbling. Late in life there is generally a fatty 
degeneration of the bladder. The prostate becomes enlarged 
in perhaps one-third of senile cases while atrophy is found in 
less than lo per cent. The hypertrophy is in the musctdar 
tissue and there are often found in the mass small fibrous tumors 
and minute calculi. Sometimes there is an increase of the glan- 
dular substance with fatty infiltration. The hypertrophy is 
generally irregular, often only one lobe being involved. In 
these cases the favorite location is the middle lobe. When 
there is atrophy, the changes are similar to the changes in the 
liver; there is a proliferation of connective tissue which forms 
bands compressing the gland substance. The ducts are fre- 
quently blocked by a deposit of lime salts. The changes occur- 
ring in the testicle are similar to the changes in other secreting 
organs i.e., formation of fibrous tissue bands which compress 
the glandular substance followed by atrophy and later sclerosis 
of the substance. The enveloping capsule becomes thick and 
closely adherent. There is a diminution in the number of the 
spermatozoa but not in their activity or functional powers. The 
duct changes are like the changes in other secreting ducts, de- 
generation and thickening of the inner coat, waste of muscular 
and elastic fibers, atrophy and sclerosis of the outer coat. The 
changes in the female generative organs begin at the menopause 
and while really senile changes they belong to the realm of the 
gynecologist. 

The changes in the brain are atrophic and degenerative. The 
waste is confined to the cerebrum, mainly at the cortex and most 



30 PHYSIOLOGICAL OLD AGE 

frequently in the left hemisphere. The loss in weight is about 
loo grams at eighty years of age. There is an increase of fluid, a 
decrease of fat, the brain is denser, there is white softening of the 
walls of the ventricles, the pia mater is thickened, there are pac- 
chionian granulations and there is an increased amount of fluid 
in the meshes. The fissures are shallower, the cortex is thinner 
and frequently contains amyloid bodies while connective-tissue 
fibers are increased. The nerve fibers are thinner, the cells are 
atrophied. In many cases minute cavities form around lymph 
vessels. These cavities called ''Etat Crible," formerly supposed 
to be perivascular spaces, are retractions of brain substance due 
to waste. Sometimes spots of miliary aneurysm and softening 
are found. Atheromatous changes in the vessels of the brain 
are more pronounced than in any other organ of the body. 
The changes in the cord are similar to the changes in the brain. 
Amyloid bodies are frequently found around the central canal, 
there is a waste of the ganglion cells of the anterior horns, 
pyramids and posterior fibers. There is a general decrease in 
volume of nervous tissue, an increase of cerebrospinal fluid, 
the cord is darker and more firm, the meninges are thickened, 
cloudy and sometimes contain osseous plates. The athero- 
matous arteries present a beaded appearance, and there are 
often spots of miliary aneurysm, hemorrhage and softening. 
Occasionally zones of sclerosis are found around the blood-vessels, 
which press upon the nerves causing them to waste. The 
changes in the nerves are probably similar to the changes in 
the cord but these changes come on late and the functional 
changes in the organs usually terminate life before changes in 
the nerves are far advanced. In the peripheral nerves parenchy- 
matous degeneration takes place in the terminals and terminal 
fibers and proceed toward the center. 

The senile changes in the eye are sclerosis of the lens and 
weakening of the muscles of accommodation; in the ear there 
is waste of the drum and a change in the auditory nerves; in 
the nose there is atrophy of the Schneiderian membrane. The 
changes in the tactile ends are not well known, but it is evi- 
dent that some change occurs as there are great functional 
changes. Neither is it known what changes occur in the taste 
btdbs. 








Group of Four Nerve Cells from the First Cervical 
Ganglion of a jNIan Dying of Old Age at Ninety-two 
Years. Specimen preserved with osmic acid. C, C, two 
cells still intact, but loaded with pigment granules; c, 
c, two cells which have disintegrated. X500 diams. 
(From Minot's "Problems of Age, Growth and Death." 
G. P. Putnam's Sons, New York and London.) 




Group of Five Nerve Cells from the 
First Cervical Ganglion of a Child at 
Birth. Specimen preserved with osmic 
acid. X500 diams. (From Minot's 
"Problems of Age, Growth, and Death." 
G. P. Putnam's Sons, New York and 
London.) 





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degeneration. (Williams Medical Record, Nov. 23, 191 2.) 



PHYSIOLOGICAL CHANGES IN OLD AGE 3 1 

PHYSIOLOGICAL CHANGES IN OLD AGE 

The changes in physiological functions in old age are due 
either to the anatomical changes or to some causes for which we 
can find no anatomical change and we therefore call them purely 
functional manifestations. Many functional changes begin 
before anatomical changes can be demonstrated and in the 
nervous system profound alteration of function may persist 
throughout life, yet postmortem examination does not disclose 
any change in the tissues. There is no relationship between the 
extent of anatomical and functional change in old age even in 
pathological conditions. Neither do the objective or subjective 
manifestations give any clue to the extent or character of the 
anatomical or physiological changes. The earliest functional 
change is diminished activity, diminished power and lessened 
vital resistance to deleterious influences. Diminished activity 
is evidenced by diminished metabolism; lessened elimination of 
CO2. Diminished power is evidenced by more rapid fatigue or 
by a greater effort required to do laborious work. This is due to 
weakening of muscle fibers. Lessened vital resistance is evident 
from the greater liability to certain diseases, tardy recovery, 
slow healing of wounds, and the frequency of sequelae. 

Omitting the functional changes due to progressive pro- 
Hferation of the connective-tissue fibers between the pyramids 
of the kidneys and those early cases of arteriosclerosis and 
cardiac hypertrophy which are due to excessive muscular activity, 
fast living, syphilis and other controllable causes, the earliest 
functional change occurs in the lungs. Until the limit of 
growth has been reached the continual deposit of dust in the 
bronchioles does not impair the respiration. Afterward this 
deposit diminishes the caliber of the tubes and the amount of 
tidal air is consequently diminished. Aeration of the blood 
is now incomplete and from this time forward the imperfectly 
oxygenated blood has a progressively lessened capacity for 
carrying nutrition to the organs and tissues and carrying off 
waste. As this is one of the fundamental causes of ageing, 
it will be discussed under that heading. The compression of 
the lungs and their diminished expansibility cause shallow 
breathing. The vital capacity is diminished at the rate of about 
I 1/2 cubic inches per annum and the amount of CO2 expired 



32 PHYSIOLOGICAL OLD AGE 

which in maturity is about 1340 cubic inches per hour falls to 
less than 1 000 cubic inches between the ages of sixty and eighty, 
and may fall to less than 700 cubic inches in extreme old age. 
The respirations are increased in frequency, there is generally 
shortness of breath, dyspnea is easily induced, the respiratory 
motion is confined to the upper part of the chest, the motion, 
being up and down and not expansive. Wheezing and persist- 
ent dyspnea are indications of advanced emphysema. 

The functional changes in the circulatory system sometimes 
correspond with the anatomical changes, occasionally there are 
marked perversions of function which cannot be explained by 
the changes that are found, and at times physical examination 
reveals anatomical and functional changes that give no objective 
or subjective symptoms. 

There is high blood pressure as long as the heart can maintain 
the circulation through a compensatory hypertrophy. When 
the demands upon the heart are greater than it can respond to, 
the blood pressure falls below normal. It may also fall through 
dilatation of the arterioles and when the blood supply to the 
left ventricle is deficient. The thickening of the aortic valve 
and the enlargement of the aortic orifice cause an insufficiency 
of the valve with the consequent regurgitation. This weakens 
the mitral valve and may cause either rupture of that valve or 
contraction of the cusps which are already thickened through 
extension of the senile endocarditis, and mitral insufficiency is 
produced. The aorta is generally dilated and its elasticity is 
diminished. These changes cause a delay in the propul- 
sion of blood and the current is slowed, the pulse being 
normally slower in old age, ranging from 65 to 75 a minute 
in the male, and from 5 to 10 beats more in the female. 
Slight influences, however, tend to increase or diminish the 
pulse rate and permanent bradycardia is not infrequent. The 
pulse in senility is no indication of the condition of the heart as 
its strength, frequency and regularity may be influenced by 
factors outside of that organ. Irregularity in strength and 
rhythm may exist in the heart without any degeneration of the 
heart muscle, the fault in such cases being in the nervous 
regulation. The heart sounds are somewhat altered, the first 
sound being rough and prolonged and the second sound louder 
than in maturity. There is occasionally a reduplication of the 



PHYSIOLOGICAL CHANGES IN OLD AGE 33 

first sound due either to irregular contraction of the ventricles 
or to mitral and tricuspid changes. There is generally an aortic 
bruit also various valvular murmurs which will be described under 
the valvular diseases. The blood current is slackened and owing 
to the contracted vessels the amount of blood in the arteries is 
diminished. As the changes in the lungs prevent complete 
aeration of blood the character of the blood is changed and it 
passes through the capillaries with difficulty. The vis-a-tergo 
being thus weakened and the vis-a-fronte being reduced through 
the changes in the right heart and lessened respiratory move- 
ments, the veins become filled with a slow-moving current of 
blood producing venosity and varix. 

Investigations into the blood changes in old age give con- 
tradictory results and lead to uncertain conclusions. In a 
series of twelve fairly healthy individuals over seventy years of 
age reported by Grawitz, the blood count showed red cells from 
three millions to over five and a half millions; white cells, from 
4000 to 8000; hemoglobin from 90 to no per cent.; S.G. from 
1048 to 1060. 

The particular ingredients which are used up in the nutrition 
of the tissues, and the method of conversion are unknown. It is 
certain that repair of waste is made up from the serum and that 
the red cells furnish the oxygen required in the process of 
metabolism, but neither the microscope nor chemical analysis 
has revealed how the changes are effected. The simple fact 
that chemical processes in the body do not correspond with 
chemical processes outside of the body would indicate that there 
is a vital factor which modifies the organic processes. Food 
subjected in a test-tube to the same enzymes that are found in 
the stomach does not undergo the same change as occurs in the 
stomach. The character of this vital factor is not known. 

With the single exception of the proliferation of connective- 
tissue cells between the apex of the pyramids, the anatomical 
changes in the kidneys show no difference under the microscope 
from the kidneys of interstitial nephritis, but there is a great 
difference in the performance of the functions. In old age the 
amount of urine is diminished, it is of lower specific gravity and 
contains less solids than in maturity, the amount of urea is 
considerably lessened and may not exceed 125 grains per day, 
while the amount of uric acid is reduced by about half. There 
3 



34 PHYSIOLOGICAL OLD AGE 

is occasionally albuminuria which has, however, little significance 
unless associated with casts. When the urine is alkaline 
immediately after voiding, it is probably due to retention in 
a dilated bladder. A dilated bladder will hold urine in the 
pouches — formed by the contraction of the muscle and con- 
nective-tissue fibers in the walls — for days; the urine decomposes 
and ammonia is produced. The physiological changes in the 
digestive organs are due partly to the changes in the organs 
involved, partly to the changed power of assimilation and 
partly to the food. With the falling out of the teeth solid food 
cannot be masticated properiy nor thoroughly mixed with saliva. 
Such food is swallowed in pieces, only the outside being acted 
upon by the saliva and excessive work is put upon the gastric 
secretions which are already diminished in quantity and probably 
changed in quality. Solid food is not absorbed unless thoroughly 
disintegrated and easily soluble. Consequently food, unless 
introduced into the stomach in such form as to be readily ab- 
sorbed, remains there for hours, perhaps days, decomposing 
or undergoing fermentation or it passes into the intestines 
unchanged giving the intestinal secretions excessive work. 

The sense of taste is obtunded, and the muscles of deglutition 
are weakened so that it requires a sensible effort to swallow. 
Owing to the anatomical changes in the stomach the gastric 
digestion is slowed and imperfectly performed. While the 
dilatation of the stomach and the waste of the muscular coat 
with the atrophy of the glands lessen the activity of the organ 
and food remains longer in the stomach than in maturity, 
weakening and waste of the muscular structure of the pylorus 
permits food particles to pass into the duodenum unchanged 
and such particles may pass through the intestines undigested. 
The rate of digestion in the stomach in old age is much slower 
than the rate of digestion in maturity. 

The most pronounced functional changes in the intestines 
are constipation, occasional diarrhea, and an excessive accumu- 
lation of feces in the colonic pouch. The first of these changes 
is due to the weakening and waste of muscle fibers whereby 
peristaltic activity is diminished. This is frequently accompa- 
nied by neglect of the aged to attend the call for evacuation of 
the bowel, and this last is the main cause of the dilatation of the 
colon and rectum, whereby pouches are formed. Here we see 



PHYSIOLOGICAL CHANGES IN OLD AGE 35 

one of the many vicious circles which are formed in old age. 
The diminished elasticity of muscle fibers permits dilatation of 
the gut which consequently becomes filled with fecal matter 
distending the bowel, this distention further stretching the 
fibers and impairing their elasticity. Senile diarrhea, while 
due to the intestinal changes, is really caused in most cases by 
improper feeding, the food being taken in too short intervals, 
in excessive amount, or by entering the intestines unchanged it 
acts as an irritant. 

Functional changes in the brain and nervous system are often 
the most marked of all the changes that occur in the organism 
and in many cases there is no corresponding anatomical change. 
Lessened coordination, slowed afferent and efferent impulses, 
weakened and often perverted sensibility, impaired activity of 
the regulating centers and various forms of mental disturbance 
may be present, yet no morphological change can be found to 
account for them. These are called senile neuroses. Some of 
the functional changes in the aged resemble the perverted 
activities associated with disease in maturity. Senile tremor 
simulates paralysis agitans but the central canal of the cord may 
not be encroached upon as is the case in the diseased condition. 
On the other hand, extensive anatomical changes have been 
found without functional changes. Bunsen, who died at the 
age of eighty-nine, was engaged in profound scientific research 
up to the time of his death, yet his brain was greatly atrophied. 
The same condition was found in the brain of Mommsen, the 
great German historian. 

Among the earliest of the functional changes in the nervous 
system are delayed and weakened impulses. Action does not 
respond as rapidly to the will, and it requires a greater motor 
impulse to perform the act while greater mental concentration 
is required to obtain and hold sensory impressions. Brain fag 
sets in more rapidly than in maturity and while the quality of 
the work may not deteriorate, the amount of work that can be 
done at a time is less. Aged writers who could write for ten or 
twelve hours without intermission during maturity must now 
take frequent rests else brain fag, then mental confusion and 
finally complete mental exhaustion set in. The rest must be 
either in the form of sleep or of some diversion which requires 
no mental exertion. When an old man falls asleep during a 
sermon or lecture, it is not through lack of interest but from 



36 PHYSIOLOGICAL OLD AGE 

brain fatigue following concentrated interest. Tendon reflexes 
are generally diminished. Ferris and Bosco found the knee 
reflex absent in 20 per cent., arm reflex absent in 71 per cent., and 
foot reflex in 81 per cent, of cases between sixty-five and eighty- 
five years of age. In over 30 per cent., however, the knee reflex 
was exaggerated due probably to waste of fibers in the pyramids. 
Sometimes the exaggerated tendon reflex is associated with 
tremor and a pronounced uncertain gait, the whole simulating 
cerebrospinal sclerosis. In such cases arteriosclerosis of the 
brain and cord are usually found and often cerebral softening. 

The functions of the sensory organs are impaired in old age. 
The sclerosis and flattening of the crystalline lens render accom- 
modation for near objects difficult and presbyopia is produced. 
Where there has been a myopia in earlier life it frequently 
happens that the senile flattening of the lens will so far reduce 
the former excessive convexity as to bring about a normal con- 
vexity of the emmetropic eye. This explains the so-called 
** second sight" of aged persons who had been obliged to use 
glasses in earlier life and can see well without glasses in old age. 
The term ''second sight" is also applied to a myopie condition 
that occurs in incipient cataract in the aged who have presby- 
opia or hypermetropia, seeing well at a distance but requiring 
convex lenses for reading. A swelling of the lens and an in- 
crease in its density during the formation of the cataract in- 
creases the refraction and the individual can now read without 
glasses but distance vision is impaired. The acuteness of vision 
is however not restored, but there is an increasing blurring and 
dimness depending upon the site, distribution and degree of 
opacity. Though rather frequent in the aged it is pathological. 
Weakened accommodation of the muscles interferes with motion 
of the organ. Owing to the weakening of the muscular fibers of 
the iris the pupils respond slowly to light, and are generally 
contracted. 

The arcus senilis which is always found in the aged does not 
interfere with sight nor does it denote fatty degeneration of the 
heart as was formerly thought. (The author has a well-marked 
arcus senilis which was shown to the class during his school days.) 

Presbyacusia (deafness) is generally present in old age and in 
many cases the loss of hearing is complete. This is due to some 
change in the auditory nerve. The sense of smell is generally 
weakened and often obliterated. This is due either to the waste 



PHYSIOLOGICAL CHANGES IN OLD AGE 37 

of the Schneiderian membrane or it may be due to atrophy of the 
olfactory nerve or to a change in the olfactory bulb. There may 
be perversions of smell for which no explanation can be found. 

The sense of taste is obtunded and occasionally perverted. 
While the sense of smell and the sense of taste probably become 
weakened through morphological changes in the nerves or end 
organs, the perversions are probably psychoses. Sensation is 
impaired in several ways. There may be anesthesia, hyper- 
esthesia and various paresthesias. These changes are due to 
the changes in the skin and terminals of the nerves. The aged 
generally feel cold. This is due to lessened surface circulation 
and impairment of the heat regulation. The weakened tactile 
sense is due to the degeneration of the tactile end organs. 
Lessened skin sensibility, anesthesia, is due partly to the mental 
weakness, the mind failing to note skin sensations unless it is 
concentrated upon the impression received, and partly to the 
nerve changes. Hyperesthesia is due to nerve changes. The 
paresthesias such as numbness, formication, itching, etc., may 
be psychic, organic, or both. 

It is not always easy to say how far mental deviations are 
natural and normal in old age and where perversion begins. 
Lessened capacity for work is an early manifestation of senile 
atrophy of the brain. In some this lessened capacity is shown in 
rapid fatigue, in some the quality of the work is impaired, in 
others it is forgetftilness. If one is a writer he finds that new 
ideas do not come as readily to his mind as formerly; that he 
must debate over the choice of words, that he must make 
corrections frequently, while formerly he could write pages with- 
out a change. If he is a reader he finds that he does not grasp 
the substance of his reading readily and that he must frequently 
read a paragraph several times if he wants to digest its import. 
He finds it more difficult to concentrate his attention and after 
reading a few pages he wants to take up some other work. 
Where formerly a single reading left a clear impression on his 
mind to be reproduced at will, now the impression soon fades 
and an effort is required to reproduce it. His interest in general 
affairs wanes but the interest in a hobby may remain unim- 
paired or may even be increased as his interest in other direc- 
tions lessens. He may in this way show greater mental capacity, 
greater reasoning power than before, but it is all exerted in one 
direction. The mind is accustomed to activity in many fields. 



38 PHYSIOLOGICAL OLD AGE 

If all its efforts are directed into one channel it will do more work 
in this one channel, even though its total capacity for work is 
diminished. It is simply the principle of economic specializa- 
tion applied to the mind. This will explain the remarkable 
works turned out by great men in all fields in their old age. 
Where there is general mental decay, the will, sensations, 
intellect and emotions become less active, the weakening being 
progressive until complete dementia is reached, and the individ- 
ual's existence is like that of the absolute idiot. In these ex- 
treme cases, however, there is usually pathological cerebral 
softening. The change in temperament which is often marked 
in old age is not a senile psychosis though generally classed 
among the senile psychic changes. It seems to me that it is the 
natural result of the realization of advancing age with diminished 
powers, lessened opportunities, increasing discomforts, and the 
fast approaching termination of life. Similar temperamental 
changes are observed in the young when they find that they are 
suffering from a fatal disease. The moment a man becomes a 
grandfather, though he be but forty, he begins to feel old and 
changes in his temperament and demeanor can be noted. Other 
causes such as a sudden fright, a secret fear, a great loss, will do 
the same. Owing to the weakened intellect in old age the 
individual loses control over the emotions, weakened memory, 
especially for recent events, makes him more conscious of the 
old order of things, he becomes "old fashioned," holding on to 
ancient ideas and methods, and becomes irritated when these 
are displaced. These idiosyncrasies become obnoxious to the 
younger generation and they look upon him as queer. The 
idiosyncrasies become more pronounced when the old man 
grows careless about his person and his surroundings, although 
this is mainly due to his desire to avoid everything that may 
cause physical exertion. Even among old women who were 
formerly extremely neat this carelessness about their sur- 
roundings is often noticed. Owing to their innate vanity they 
may, however, present an appearance of neatness though often 
this applies only to externals. Among the depressing influences 
of early senility is diminution of the sexual powers without 
diminished desire. Where desire and power diminish together 
this is not noticed, but the loss of the power alone often leads to 
the sexual perversions of the exhibitionists. Mental weakness 
produces an expression of apathy; in mental depression there is 



CAUSES OF AGEING 39 

moroseness, irritability, often pre-occupation (day dreaming), 
the individual talks to himself, sometimes exhibiting anger or 
fear upon the slightest provocation or without any apparent 
reason. (The changes during the senile climacteric have been 
described in the chapter on The Senile State.) 

CAUSES OF AGEING 

The question why we grow old, or rather why, after a period 
of physical perfection the organs and tissues degenerate and their 
functions become weakened and perverted until they are unable 
to maintain the harmonious interrelations necessary for life, is 
part of the great problem of life and death. Natural phenomena 
require scientific explanations. Recourse to unnatural, super- 
natural and superhuman agencies, a belief which can only be 
based on faith, is simply an evasion of a scientific explanation. 
Of the metaphysical trinity — the beginning, life and the here- 
after, life is the one which is tangible to the extent that its 
manifestations may be studied. The natiu'e of the force which 
we call vitality is unknown, but we cannot say that it is unknow- 
able. A scientific theory of life must have a comprehensible 
basis though we may not be able to prove the theory or the 
existence of the basis, with our present methods of investigation. 
When we fall back upon ' 'the will of God " or " fate " or " nature ' ' 
as our explanation of life and its manifestations, we accept the 
basis on faith and not on fact or reason. We know that life 
depends upon the existence in the protoplasm of a property 
called irritability. When that property is absent the protoplasm 
is only a highly complex chemical which we have not yet succeeded 
in making synthetically. Ageing is a manifestation of life. 
It is found throughout the animal and vegetable kingdom ; trees 
show the effects of age and even among the infusoria there are 
changes which result in their death and which are considered to 
be senile degenerations. Many theories have been advanced 
to account for this ageing. The old idea that the body becomes 
worn out like an old engine and the tissue wastes just as the 
material wears away in machinery or goods, is a fanciful simile 
without a basis of fact. There is no similarity between the 
wear and tear of material through friction or by the elements 
and the waste of tissue, except in the wear of the epidermis. 
Neither does the body become worn out through activity, indeed 
in the early period of life activity hastens repair and growth. 



40 PHYSIOLOGICAL OLD AGE 

There is no analogy between the metaboHc processes and the 
wear and repair of inanimate things. Organs and tissues that 
are rarely or never used in one individual undergo the same 
degenerative changes that occur where they have been actively 
employed in another. The virgin uterus undergoes the same 
change at the menopause that occurs in the uterus of the multipara. 
The brain of the absolute idiot shows in advanced age the same 
changes that go on in the brain of the sage. In old age repair is 
not as active as in youth and excessive activity hastens waste, 
but this is the result and not the cause of the senile changes. 
There are two prominent histo-mechanical theories; that of 
Demange and the more recent theory of Thoma. Demange 
ascribed the cause of the senile changes ''to a change in the 
quantity and quality of the interstitial nutritive material due 
to changes in the circulation and this is due to atheroma and 
arteriosclerosis. ' ' Tracing back the cause of the vascular changes 
he believed that the constant friction of the blood against the 
inner coat of the vasa vasorum irritated the endothelium, this 
persistent irritation producing an endarteritis, with thickening 
of the inner coat and consequent diminished caliber of the fine 
vessels. The supply of nutrition to the larger vessels being thus 
diminished they begin to degenerate through fatty infiltration 
and production of atheroma. The subsequent senile changes are 
due to diminished nutrition following diminished caliber of the 
nutrient vessels. This theory followed the work of H. Martin 
on the pathogenesis of atheroma. Martin found cases of ob- 
literating endarteritis of the vasa vasorum followed by a necrobi- 
otic infarct in the larger vessel. The affected cells excite further 
irritation in the surrounding tissue of the vessels, producing vari- 
ous forms of degeneration, thereby interfering with the circula- 
tion through them. Thoma believes ''that the ceaseless activity 
of the heart and blood-vessels gradually weakens the elastic 
fibers of the vessels as would happen in a piece of rubber which is 
expanded and contracted with ceaseless regularity. The loss of 
tone thus occasioned permits a dilatation of the vessels, the 
circulation is slackened partly through the dilatation and 
partly through the lessened contractility of the vessels and the 
nutrition of the organism is thus impaired." There are several 
other theories giving nutritional changes following vascular 
changes (atheroma and arteriosclerosis) as the cause of ageing, 



CAUSES OF AGEING 4I 

differing, however, from Demange as to the cause of the arterial 
degeneration. The principal objection to the theories which 
charge the senile changes to arteriosclerosis is that arterio- 
sclerosis occurring in maturity in connection with other diseases 
and even without any other pathological condition is not 
followed by such changes as occur in old age. Another class 
of theories is based upon the assumption of the existence of a 
vital principle. This assumption has no demonstrable basis. 
If there is a concrete something, which is the essence of life and 
which causes all the changes that constitute life, we can form no 
conception of its character. If we say it is the soul we have 
again an inexplicable, intangible, immaterial something not 
susceptible of scientific proof. Vitality itself may be a form of 
energy not bound by the physical laws with which we are 
familiar, since no other form of energy can be converted into it, 
and it is subject to final extinction. This, however, does not 
justify the assumption of a vital principle, nor is there any other 
scientific basis for such assumption. Durand-Fardel's theory 
was based upon the existence of a vital principle of limited 
duration. He believed that in animal life, as in some forms of 
plant life, when the organism had completed its purpose to 
reproduce the species and thus perpetuate the race, there was 
no further object in its existence. 

After the menopause in woman and the critical period of man, 
heteroplastic processes take the place of the normal anabolic 
processes and these lead to such changes in the functions that 
their harmonious interaction is impossible and death results. 
It is hardly necessary to show the fallacy of this theory since 
physical life is not dependent upon sexual activity. The most 
prominent theory of ageing to-day is Metchnikoff's theory or 
rather theories, of tissue phagocytosis and autointoxication 
through the absorption of the products of intestinal decomposi- 
tion. The theory that the waste of tissue in advanced age is 
due to the destruction of the tissue cells by macrophages has 
been criticized on the ground that in many tissues where there 
is extensive waste no macrophages are found and the waste can 
be explained by insufficient nutrition. Even in the brain 
where Metchnikoff demonstrated the presence of neurophages in 
the aged, atrophy has been found without neurophages. The 
theory of autointoxication through the absorption of ptomaines 
and other toxic material from the intestines, which the organism 



42 PHYSIOLOGICAL OLD AGE 

is unable to eliminate, is even less tenable. While such absorp- 
tion undoubtedly takes place in old age it also occurs in maturity 
and youth, without producing senile changes. Defective 
elimination of leucomaines and other waste products of meta- 
bolism has been given as a cause of ageing but the criticism 
applied to the autointoxication theory of Metchnikoff , applies to 
this. A discussion of all the theories and the many theoretical 
and practical objections to them would carry us beyond the 
purpose of this work. Some theories are based upon some 
change in the character or composition of the blood, yet there is 
no uniformity in the changes of the blood in old age. A recent 
theory of this nature is based upon unstable metabolism. This 
causes a change in the blood salts and a consequent abnormal 
di osmosis, which impairs the circulation. The changes in the 
blood irritate the lining of the blood-vessels causing arterio- 
sclerosis, which further interferes with the circulation and the 
nutrition of the organs and tissues. 

Sir Victor Horsley's theory that ageing is due to degeneration 
of the thyroid gland, and Lorand's elaboration of that theory 
including other ductless glands, do not give us the cause for the 
senile degeneration of these glands and ageing may occur 
without demonstrable changes in these glands. 

Naunyn presents a double theory, waste and wear of tissue 
during activity, which is not fully repaired, and weakening of the 
heat-regulating centers. He points out the deficiency in the 
organism to repair the loss of elasticity in the arteries caused 
by activity, and sees therein a general fault in the organism to 
make good the losses occasioned by activity. The virgin uterus 
at the menopause and the brain of the idiot in old age dispose of 
that part of his theory. He also says that the local loss of heat 
from the surface causes general loss of heat. In maturity this 
loss is replaced through muscular activity, and this in turn creates 
the necessity for food to replace the waste of muscle. In 
senility the heat regulation is weakened and the loss of local heat 
does not arouse the same necessity for muscular activity nor is 
there the same desire for food. Lessened food produces lessened 
nutrition to repair waste and less fuel for combustion. The 
objection to this theory is that lessened muscular activity is due 
to the anatomical changes in muscles and joints making motion 
more difficult, and that the desire for food, though stimulated by 
muscular activity, exists without the necessity for such stimu- 



CAUSES OF AGEING 43 

lation as is seen in the paralyzed person, while forced feeding in 
old age does not increase the repair of waste. The slightly 
lower temperature found in the aged can be accounted for by 
the lessened muscular activity and also by lessened metabolism. 
(The senile individual requires only from 75 to 80 per cent, of 
the calories required in maturity.) The diminished surface 
temperature is due to impaired surface circulation and changes 
and not to weakened heat regulation. There are several theories 
based upon cell changes. Ever since Schwann presented his 
famous cell theory, investigators have sought in the cell the 
solution of the problems of life, of birth, of growth, decay and 
death. The earliest of the cell theories was presented by Can- 
statt. He believed that the cause of ageing was to be found in 
the cell, that the death of the cell was so much molecular death 
of the organism which was not replaced. Canstatt did not take 
into consideration the repair of tissue through cell reproduction 
or that in the course of a long life probably every cell that 
existed at birth had been destroyed and replaced repeatedly. 
Minot gives as his theory of ageing an increase in the proto- 
plasm and a differentiation of the cells. 

The theory of tissue-cell evolution which I advanced as the 
fundamental cause of ageing is based upon some facts and some 
assumptions. I believe that there is a progressive evolution in 
cell life; that newer cells differ from their predecessors; that at 
one stage of this evolution the cells are most perfectly adapted 
to their surroundings and their available nutrition; that at this 
time the cells are in the most perfect condition to perform their 
functions; that later cells are less perfectly adapted to the 
conditions under which they exist; that under these circum- 
stances fewer and more imperfect cells are formed ; that finally 
the cells are so imperfect and so poorly fitted for the conditions 
under which they exist that they either do not reproduce or else 
the organs which they form cannot perform their functions. 
Furthermore, different kinds or classes of cells have different 
stages or periods of evolution, but tissue cells of the same kind 
pass through the same stages. 

We know little of the properties of cells. They have the 
power of selection of nutrition, of assimilation, of excretion, of 
growth and reproduction, and some have the power of motion. 
The why of their activity is as much a mystery as is the source 
of their vitality. Ivlay it not be that in the course of the con- 



44 PHYSIOLOGICAL OLD AGE 

stant destruction and reproduction of cell life that is going on 
in the organism there is also going on a constant evolution in 
cells ? It would be analogous to what is going on in the more 
complex forms of life. No animal reproduces its exact counter- 
part. There is a difference in oysters coming from the same 
spawn, in trees growing from the seeds of the same apple. 
Under the microscope a whole colony of germs of the same 
variety may look alike yet under the influence of a germicide 
some will survive longer than others. If they possess greater 
vitality it is because they possess qualities or properties making 
them more resistant to deleterious influences. 

There is a difference in the properties of the protoplasm of 
different kinds, and to the difference in the proteid molecules 
is due their diverse activities. They differ in their special 
properties, the performance of specific functions, and the general 
cell properties, growth, assimilation, etc. They also differ in 
their tenacity of life, in their resistance to unfavorable influences, 
violence, temperature changes, change of nutrition, phagocytes, 
etc. Slight differences may be found in tissue cells of the same 
variety taken at the same time from the same tissue, but we 
will never find the great differences that exist at different evolu- 
tionary stages of the same tissue; that is to say, we will never 
find at the same time, for example, degenerate senile cells of the 
ovary and the early immature cells, though we may find, during 
the menopause, active cells and cells showing early degenerative 
changes. Of course, under abnormal disease conditions cells of 
different stages of evolution, imperfect cells, even cells of entirely 
different character may be found together. The difference in 
the length of the period of evolution in different cells can be 
shown by comparing the cells of the thymus gland with connect- 
ive-tissue cells. The first indication of this gland is a faint 
line which appears about the tenth week of intrauterine life. It 
grows like all tissues, through cell growth and reproduction, 
the cells becoming larger and more numerous. The cells formed 
about the second or third year of the person's life are best 
adapted to the available nutrition, to their surroundings, and to 
the conditions under which they exist. The cells and the 
organ have now reached their limit of size and activity. No 
satisfactory explanation has yet been given for limitation in 
size, whether it be cells or elephants. To account for the retro- 
grade evolution of the thymus we must reason from analogy. 




Left femur of a colored man. Large black 
spaces represent senile absorption of bone. 




A single Haversian system, 
much enlarged, without defi- 
nite signs of sensility. 




A single Haversian system, 
much enlarged, showing early 
signs of senihty. 





A single Haversian system, A single Haversian system, 

much enlarged, showing a later much enlarged, showing the 

stage of senility. latest stage of senihty. 

Senile changes in the human femur. (J. S. Foote, Smithsonian Miscellaneous Collec- 
tions, Vol. 6i, No. 8.) 




The skull of a woman eighty-three years old, to show the changes in the mandible 
and maxilla. (From ^Morris' "Human Anatomy.") 




Spinal perpendicular index. Showing relation of length of spinal column to 
perpendicular line from atlas to tip of coccyx. Infancy, loo : 95-97. Matu- 
rity, 100: 88-95. Old age, 100 : 80-90. 



CAUSES OF AGEING 45 

At the time that the cells are in their most perfect condition 
they receive an ample supply of nutrition from the blood and as 
there has been a constant increase in the rate of reproduction 
newer cells are formed more rapidly than the waste of old cells. 
But the limit of available nutrition has been reached. The 
amount of blood has increased, but with the change in diet 
and the increase in physical activity there has taken place a 
change in the condition and composition of the blood, it does not 
contain enough of the particular ingredients necessary to supply 
the thymus cells. The newer cells are consequently not in such 
perfect condition as their predecessors, they are more readily 
destroyed and they reproduce more imperfect cells. The cells 
are now in the stage of retrogression, fewer and more imperfect 
cells are formed until about the period of puberty or a few years 
later when the cells become extinct. The entire period of evolu- 
tion of the thymus gland cells is from about fourteen to twenty 
years. 

The evolutionary changes in the connective-tissue cells pro- 
ceed so slowly that it is not until late in life that any marked 
change in them is observable and then it is an increase in rate of 
growth and reproduction. It is impossible to follow up the 
evolutionary stages of connective cells as the destruction of 
their microcosm, the individual, ends their career while in the 
stage of active progressive evolution. Let us apply this theory 
to the ovarian cells. From the beginning in intrauterine life 
there is a slow, steady growth in number and size of the tissue 
cells, until at the time of puberty they are most perfectly 
adapted to their surroundings, their nutrition, and the purposes 
of the immature organ, but they are not adapted to the great 
purpose of the ovaries as reproductive organs. The period of 
puberty is a transitional stage in the evolution of ovarian tissue 
cells, the evolutionary changes proceeding rapidly, the newer 
cells having functional properties not possessed by their predeces- 
sors, the older inactive cells disappear, and by the end of that 
period only new, active cells remain. For the next thirty years, 
the period of sexual activity, evolutionary changes proceed slowly, 
for years they are apparently stationary. Toward the end of 
the active period the organ becomes less active but is still able 
to perform its functions. The menopause is another transi- 
tional stage. The old cells are still active but the newer cells 
have not the same properties as their predecessors, the activity 



46 PHYSIOLOGICAL OLD AGE 

of the organ decreases with the gradual destruction of the old 
active cells, and at the close of this period the organ is composed 
of cells having different properties from the cells of the active 
period. These new cells are not perfectly adapted to the con- 
ditions under which they exist and they reproduce cells still less 
fitted for those conditions. Fewer and more imperfect cells 
are formed, and the organ shrinks. The late cells are very tena- 
cious of life and persist throughout the life of the individual. 

While cells of the same variety pass through the same evolu- 
tionary stages, there may be wide variations in the length of time 
required to pass through each stage. Hyperplasia of connective 
tissue may begin in the thymus gland in the second or third 
year, when that organ first begins to retrograde, in the ovary 
at the menopause, in the brain at advanced old age. Puberty 
changes may occur in one person at eleven or earlier, in another 
at sixteen. 

This theory is opposed to the theory of the sudden conversion 
of one variety of cell into another variety of cell, as the passive 
cell of the hair cylinder into an active phagocyte; it is not, how- 
ever, opposed to the rapid conversion through intermediate cells, 
as the ovarian cells of the anteclimacteric period into the cells 
of the postcHmacteric period. Pathogenic causes may produce 
sudden and revolutionary cell changes, but such are not con- 
sidered in normal processes. This theory of tissue-cell evolu- 
tion will explain the greater resistance to disease and deleterious 
influences at one period of life than at another and in one tissue 
or organ than in another, the formation of pathological proc- 
esses and their preference of location, morbid selection, per- 
verted activity, and the whole cycle of the processes of life from 
its inception to its dissolution. 

The most important factor in the life of the cell is its nutri- 
tion, which is derived from the constituents of the blood. Im- 
pairment of the blood, either through the presence of abnormal 
constituents or some alteration in quantity or quality of the nor- 
mal constituents, affects only those cells which derive nutri- 
ment from those impaired constituents or assimilate the toxic 
material. These cells are weakened, their activities are im- 
paired, and they reproduce defective cells. With the improve- 
ment in nutrition and other conditions necessary for their ex- 
istence the cells improve and reproduce more perfect cells. 
This is the process of recuperation. In senility the cells of most 



CAUSES OF AGEING 47 

tissues are retrograding, and they are not well adapted to the 
available nutrition and surroundings. If there is any perver- 
sion of this nutrition, cell destruction proceeds faster, reproduc- 
tion is either abolished or the new cells are so defective that the 
organs which they form can barely perform their functions. 
With an improvement in the nutrition there may be an improve- 
ment in the cells, but the blood in old age does not furnish the 
best nutritive material to senile cells and these cells reproduce 
cells still more imperfect than themselves. The altered meta- 
bolism in old age is due to the altered properties of senile cells. 
Late cartilage cells seem to have a "liking" for calcium salts, 
that is to say, having the power of selection of nutrition they 
absorb such salts from the blood more readily than the cells at 
an earlier period. Other senile cells show the same tendency. 
Late cells seem to be tenacious of life for they effectually resist 
bacteria and other agents destructive to earlier cells. 

According to this theory the vital resistance of the individual, 
that is the power of the organism to resist certain pathogenic 
influences, is increased in old age. This is diametrically opposed 
to the generally accepted view that the vital resistance in the 
aged is diminished in all directions, yet it is well known that 
infectious diseases are rare in old age, that acute inflammations 
rarely occur and that most diseases that are apt to occur in the 
aged, except those arising from perversions of the normal senile 
processes, are modified and less active at that period of hfe. 
It is evident then that either the aged cells offer greater resist- 
ance to pathogenic germs or that phagocytosis is more active. 
The latter would account for the milder attacks of infectious 
diseases the former for their rarity. Probably both factors 
prevail in old age. Disease in old age is generally due to some 
perversion of the normal degenerations due to age, or to a dis- 
turbance in the harmonious relations between the functions, 
caused by a more rapid degeneration in one organ than in a co- 
related organ. Where the harmonious relations are maintained 
to the end, physiological death ensues without disease. In 
such cases death is due to diminution in nervous activity to the 
point of complete cessation. 

Senescence is not due to any one cause. There is undoubt- 
edly a determining factor which is the subject of the various 
theories that have been advanced, but there are in addition 



48 PHYSIOLOGICAL OLD AGE 

contributing factors, causative and resultant, which hasten the 
senile processes. With the first breath that the infant draws 
it inhales dust and the foundation of pneumokoniosis is laid. 
During the period of lung growth the increase in substance and 
size of the vesicles prevents any impairment from the deposit 
of dust in the tubes, finer bronchioles, alveoli, lymph spaces and 
connective tissue. After the lungs have ceased to grow the 
deposit continues, the lumen of the finer tubes is diminished, 
the dust sets up a pulmonary fibrosis, less air passes through 
the lungs and the blood is insufficiently oxygenated. Im- 
perfectly aerated blood causes imperfect nutrition and im- 
perfect elimination of waste. In addition to this there are 
going on in the chest walls senile changes which compress 
the lungs, diminish their expansibility and thereby further 
impair the respiratory functions. The greater effort required 
to get sufficient air into the lungs, shown by the increased 
number of respirations, puts a greater strain upon the respira- 
tory muscles, and the greater activity aroused increases the 
waste which is not fully repaired owing to the vitiated condition 
of the blood. At the same time the greater effort required to 
force sufficient air into the lungs and the impaired nutrition of 
the vesicular walls weaken the walls of the latter, they become 
thin and finally rupture producing senile emphysema with 
diminished aerating surface, increased residual air and lessened 
vital capacity. In the meanwhile changes have been going 
on in the heart and blood-vessels, the blood supply is diminished 
and later when the heart becomes weakened the pulmonary circu- 
lation is weakened, still further impairing the oxygenating func- 
tion of the lung while the impairment of the bronchial artery and 
the vitiated blood prevent the complete repair of the lung tissue, 
which wastes more rapidly in its efforts to carry on its functions 
under difficulties. In this resume of the changes that go in the 
lungs in ageing we find as the most important contributing 
factor a pneumokoniosis that began at birth. A dust-free 
atmosphere is theoretically conceivable but practically impos- 
sible. It is true that most of the dust inhaled is caught in the 
cilia of the bronchi and is expectorated but some does reach the 
finer vessels, gets into the lymph channels and into the substance 
of the lung. This is inevitable. This pneumokoniosis is not 
to be considered in the same hght as the vocational dust diseases, 



CAUSES OF AGEING 49 

as the latter are entirely independent of the senile changes and 
cause a controllable irritation in the lung which leads to lung 
destruction. 

Other contributing factors to the senile changes cannot be even 
theoretically remedied. In the spleen, for example, there is 
proliferation of connective-tissue fibers, some of which compress 
portions of spleen substance causing it to atrophy, and some of 
the fibers crossing blood-vessels compress and finally obliterate 
them thereby depriving the spleen substance of nutrition. 

Disease is not a causative nor even an essential factor in physio- 
logical death, for disease is unnatural and in the nature of an 
accident. Physiological death occurs without a perversion of 
function or structure which is the essential element in disease. 
Sanitation, hygiene and dietetics serve to prevent disease but 
they have no influence in prolonging life aside from the preven- 
tion of disease. The longevity of the Jews under the most 
unsanitary conditions is proof of this statement. Other long- 
lived nations such as the Bulgars, Roumanians and Russians 
reach an advanced age in utter disregard of sanitary regulations. 

The prevalence of precocious senility in nations which sub- 
ject themselves to intense mental and physical activity strength- 
ens the theory of tissue-cell evolution as the determining cause 
of ageing. This excessive activity hastens the evolution of the 
cells, by causing greater activity with consequent more rapid 
destruction and reproduction and the earlier appearance of 
cells of the later evolutionary periods. I have not touched 
upon the factor of heredity as I do not believe that heredity has 
any direct influence upon longevity. Healthy parents beget 
healthy children and if the children live under the same condi- 
tions as their parents, they have the same chance to reach old 
age. The farmer's son who remains on the farm will age more 
slowly than his brother who goes to the city. 

The theory^ of tissue-cell evolution is in accord with what we 
know of evolution in the higher and more complex forms of life. 
What the eon is to the universe and the geological period is to 
mundane life the years of an evolutionary stage are to the cell. 
A gradual and progressive process, cell evolution is the natural 
conclusion that has cosmic evolution as its major and race evolu- 
tion as its minor premises. 

^ This theory of senescence was first pubHshed in the New York Medical Journal, 
Nov. 5, 1910. 



PART II 
PATHOLOGICAL OLD AGE 



GENERAL CONSIDERATIONS 

Disease in old age must be looked upon not as a pathological 
process in an organ or tissue such as we find in maturity com- 
plicated by senile degenerations, but as a pathological process 
in a normally degenerating body, and the perversion of function 
is not a perversion from the normal functions of maturity 
but a perversion from the functions that are normal to the 
degenerating body. This conception of disease in old age will 
lead to a discriminative valuation of the symptoms and signs 
of disease and the manifestations of senility. The latter are 
often more pronounced than the symptoms of disease and unless 
we can separate the manifestations of normal senile processes 
from the symptoms of disease and eliminate the former from 
our diagnosis, we will treat an incurable, progressive, physio- 
logical degeneration while the disease is killing the patient. 
Not infrequently the manifestations of old age simulate the 
symptoms of a disease and the patient is treated for a patho- 
logical condition which is not present. Another frequent source 
of error in diagnosis is due to obscure symptoms which may be 
unnoticed or uninterpretable. This is often the case in senile 
pneumonia, the symptoms of which are at times so mild as to 
arouse no suspicion of the grave pathological condition present 
until pulmonary edema sets in. Another source of error in 
senile cases is in the interpretation of symptom complexes. 
We often find in maturity a number of symptoms which taken 
collectively are diagnostic of a certain disease. In senility 
every symptom must be traced to its source before we can 
determine its relation to the disease which we suspect. In 
senility the severity of symptoms bears no relation to the 
severity of the disease nor does moderation of symptoms always 
denote an improvement in the pathological conditions. A fall 

51 



52 PATHOLOGICAL OLD AGE 

in temperature may be due to exhaustion which ends in death. 
A rapid fall in blood pressure may be due to sudden weakening 
of the heart, the sleep after delirium may be a coma from which 
the patient will never be roused. A rapid loss of weight may 
be due to waste of fat and the wrinkled skin after such loss 
gives the individual the appearance of age. A rise in tempera- 
ture is invariably due to disease and the more rapid the rise 
the more serious the disease. If a chill precedes the rise in 
temperature we have a grave condition which will probably end 
fatally. Temperature changes are, however, uncertain indica- 
tions of the character or severity of a disease, and unless the 
temperature is taken in the rectum it is misleading. Even 
in health in the aged there may be a difference of two degrees 
between the rectal and axillary temperature and the same 
difference can be found in the mouth at different times. It 
is not unusual to find a mouth temperature of 97 or less in per- 
fect health. Elevation of temperature as the result of disease 
proceeds less energetically, more slowly, and does not rise as high 
as in the same disease in maturity. If the mouth temperature is 
taken as is generally done in adults, we are liable to be several 
degrees out of the way and we will get an intermittent or septic 
temperature range due to local causes not connected with 
the disease. The typical temperature curves associated with 
certain infectious diseases are rarely seen in old age. It cannot 
be insisted upon too strongly that temperature in the aged 
should be always taken in the rectum only. The pulse in old 
age is worse than useless as a diagnostic agent, for it will often 
deceive us. As arteriosclerosis is almost always present, the 
artery is harder than in maturity and we get a hard pulse that 
may simulate the pulse of serous inflammations. We may 
get this pulse in aortic stenosis in which condition the pulse is 
usually small, slow and weak and we may get the same pulse in 
aortic insufficiency in which disease in maturity we get the 
water hammer pulse. There are many conditions beyond the 
aortic orifice to modify the radial pulse and destroy its value as 
a diagnostic agent. Blood pressure in the aged has not been 
studied sufficiently nor have similar findings received similar 
interpretations. As we have in almost every senile case 
arteriosclerosis and contracted kidney, two causes for increased 
pressure, high readings are physiological but no standard for 



GENERAL CONSIDERATIONS 53 

senile cases has been established nor are investigators agreed 
upon the meaning of deviations from the usual findings in the 
aged. The closest approximation of a standard of normal 
blood pressure in the aged is the age plus loo in m.m. The face 
gives us little information in senile cases. There is the expres- 
sionless face of senile dementia and of paralysis agitans, the 
latter disease being readily distinguished from the former by 
the tremor and brighter mentality. There may be jaundice 
indicating biliary obstruction or cancer; in apoplexy the face 
is puffed and congested; in chronic nephritis puffy and muddy 
or pasty looking; it is flushed in hyperemia and fevers, pale 
in anemia, sallow in various cachexias; but these facial indica- 
tions have only a secondary value. Almost every one who has 
reached advanced age has led an out-door life, his skin is 
tawny and weather-beaten and does not readily show these 
changes. The contracted pupils which are normal to old age 
may mislead us, the dribbling of sahva may suggest salivation, 
occasionally one sees the stare which, associated with contracted 
pupils, is found in mania. This will be found in the aged indi- 
vidual who has presbyopia and does not wear his glasses when 
he makes an effort to see a speaker close by. Ordinarily the 
aged patient is apathetic or if he reaHzes the seriousness of his 
condition he is anxious or depressed. In most diseases having 
a fatal outcome, the mind becomes dull and as the end 
approaches the patient becomes unconscious. Pain is an 
uncertain symptom in old age, as it is frequently referred to 
some organ or tissue not diseased and it is often absent or sUght 
in diseases in which pain is usually a prominent symptom. 
The absence of this symptom in pneumonia, gastritis, peritonitis, 
etc., may lead to a wTong diagnosis or to the neglect of the 
disease by the patient himself until death ensues. Gangrene 
seldom gives pain and it may be neglected until extensive 
necrosis has occurred. This absence of pain in senile diseases 
is usually associated with weakened mentaHty and it is probable 
that the mental condition is responsible for the lack of apprecia- 
tion of painful sensations, as well as the condition of the nerve 
terminals. There may be on the other hand hyperesthesia and 
paresthesia, especially itching, so severe as to require medical 
attention, yet no pathological lesion can be found. The 
altered reflexes in old age frequently make a correct diagnosis 



54 PATHOLOGICAL OLD AGE 

difficult and if the disease is one in which the state of the re- 
flexes is diagnostic or confirmatory of a diagnosis, it is almost 
impossible to avoid error. Investigators have found the foot 
reflex absent in over 80 per cent, of cases between sixty-five 
and ninety-three years of age, yet the knee reflex was increased 
in 32 per cent, and absent in but 20 per cent. These findings 
show the unreliability of the state of the tendon reflexes as a 
diagnostic aid in old age. If there are two conditions present 
which ordinarily give different reflexes we must omit the 
tendon reflex entirely in determining our diagnosis. A fre- 
quent source of error in diagnosis in senile cases is the changed 
position into which organs are forced through anatomical 
changes in other structures. The flabby abdominal muscles 
and weakened diaphragm permit the liver to sink until in excep- 
tional cases the upper border can be felt below the ribs. In 
these cases the organ appears to be much larger than when the 
outlines can be determined only by percussion. The stomach also 
sinks when the abdominal walls are flaccid and the intestines 
are empty, but when the bowels are filled with flatus the stomach 
may be raised or pushed to one side. Owing to the rigid chest 
walls and wasted intercostals the apex beat may be quite pro- 
nounced even in the case where the heart is weak as in cardiac 
dilatation. The weakened diaphragm allows the heart to sink 
until the apex is 3 inches below the nipple and further to the 
left than in maturity, yet a dilated stomach or intestines dis- 
tended with gas can raise the diaphragm and push the heart 
further up and to the left. In determining the meaning of an 
abnormal position of the heart, the condition of the stomach 
and intestines must be taken into account. Owing to the 
rigidity of the chest walls inspection gives us little information 
of pathological conditions within the walls, while the up and 
down respiratory motion is apt to mislead us. In senile pneu- 
monia the apex is generally affected, but the lungs in old age are 
atrophied and we must look for the altered percussion note in the 
infraclavicular space. Shght bulgings between the ribs are 
generally due to pleuritic effusion, but owing to the rigid chest 
walls the diagnosis must be made by percussion and ausculta- 
tion in different positions. The interpretation of heart murmurs 
occasionally gives some trouble if two or more valves are affected, 
especially if in addition there is an aortic bruit. Combined val- 



GENERAL CONSIDERATIONS 55 

vular defects are the rule in old age and when the rhythm is 
irregular it is often impossible to make a diagnosis from the mur- 
murs alone. It is sometimes necessary to feel the carotid pulsa- 
tion or the apex beat to determine whether a murmur is systolic or 
diastolic. In aortic stenosis the murmur may be loud enough to 
mask the less audible systolic murmurs of mitral regurgitation 
and dilatation of the arch of the aorta, while in aortic and mitral 
regurgitation and in aortic obstruction with dilated aorta — the 
most frequent combination of valvular lesions — systolic and 
diastoHc murmurs are heard all over the chest and the diagnosis 
must be made by accompanying symptoms and signs. Not- 
withstanding the vastly inferior methods of diagnosis of abdom- 
inal disorders as compared with the methods applicable to tho- 
racic diseases, errors in diagnosis are less liable to happen in the 
former class of cases. The principal sources of error in abdominal 
disease are absence of pain in usually painful diseases especially 
inflammations, abnormal position of organs or tissues, symp- 
toms apparently connected with other organs than the one dis- 
eased, symptoms referable to a diseased organ but differing 
from the ordinary symptoms of the suspected disease, and mani- 
festations of seniHty simulating a disease. Some of these sources 
of error have already been discussed. An example of symptoms 
referable to other than the diseased organ is seen in the asthma 
and vertigo frequently associated with acute gastritis, and some- 
times more pronounced than the gastric symptoms. The ab- 
sence of prominent symptoms of a disease occurs more frequently 
than the presence of exceptional symptoms. Postmortem ex- 
aminations frequently reveal lesions that gave no symptoms dur- 
ing life, even of such diseases which give pronounced symptoms 
and signs when occurring in maturity. Gastric ulcers have been 
found after death in cases where there had been no pain, vomit- 
ing or hyperacidity during life. Vomiting is, however, frequently 
absent in old age in diseases in which it is a prominent symptom 
in maturity. Diarrhea is comparatively infrequent in the aged 
and in almost every case can be traced to some fault in the food. 
When it occurs in connection with other diseases it has little or 
no diagnostic value. Constipation, when the only symptom, is 
generally due to diminished peristalsis and has no diagnostic 
value, except as an expression of the physiological senile changes 
in the intestines. When associated with other symptoms not 



56 PATHOLOGICAL OLD AGE 

due to the constipation, its significance is uncertain. (This 
and diarrhea will be discussed fully in the article on senile 
changes in the intestines.) In many cases of abdominal disease 
the etiology and history of the case will give more information 
than the symptoms and signs. On the whole the diagnosis of 
this class of diseases is not difficult if we remember the senile 
changes and eliminate their normal manifestations. Far more 
difficult is the diagnosis of diseases of the nervous system owing 
to the diverse character of the senile changes in the organs, and 
their manifestations. It is often a question of personal opinion 
whether the functional changes are normal or abnormal, physio- 
logical or pathological. The difficulty is increased through the 
resemblance of some of the altered functions to the impaired func- 
tions of certain disease conditions. The senile gait and senile 
tremor may resemble the gait and tremor of paralysis agitans, the 
senile dementia of cerebral atrophy is like the dementia of cere- 
bral softening and the dementia following melancholia; the 
changed reflexes in old age suggest various nervous diseases. 
The altered reflexes and weakened power of coordination that we 
frequently find are symptoms of well-defined diseases, yet 
postmortem examinations may fail to show the lesions asso- 
ciated with such diseases. Notwithstanding these difficulties the 
practical elimination in old age of tabes dorsalis and diseases in- 
volving increased functional activity simplifies the diagnosis. 
Of the general neuroses senile tremor and paralysis agitans are 
most frequent, and neurasthenia is sometimes seen. Vertigo 
occurs quite frequently in old age and is almost always due to 
cerebral arteriosclerosis. Of the psychoses, melancholia and 
hypochondria are frequent, occasionally there is amentia or 
paranoia, rarely mania. There is little difficulty in their diagno- 
sis. Dementia is the usual outcome of the psychoses of old age 
and the termination of senile atrophy and cerebral softening. A 
temporary dementia may follow apoplexy. Arteriosclerosis of 
the cerebral vessels is the most frequent cause of mental impair- 
ment and the same disease in the vessels of the cord is responsible 
for many of the diseases of the cord and spinal nerves. Men- 
ingeal diseases are rare in old age and when they do occur at that 
time of life they are almost always secondary. Other cerebral 
diseases, such as anemia, hyperemia, hemorrhage, embolus and 
thrombus and the diseases resulting from them, are generally 



GENERAL CONSIDERATIONS 57 

traceable to atheroma and present no serious difficulty in their 
diagnosis as they do not differ from the same diseases occurring 
in maturity. Some writers describe a senile paraplegia as a 
distinctive disease, but there is no unanimity in their description 
of the disease and they agree only on one symptom, a progres- 
sive weakness of the lower limbs. As this may be due to various 
conditions of the brain and cord and to the physiological changes 
caused by ageing — perhaps to the simple waste of muscle — the 
term senile paraplegia will be used to denote the one symptom and 
not a well-defined disease. The most frequent spinal disease 
in old age is myelitis, although there are frequently symptoms 
pointing to other degenerative diseases, principally to degenera- 
tion of the lateral and posterior fibers. The principal disorders 
of the peripheral nerves are neuritis, neuralgia and disorders of 
sensation and of the special senses. In some cases it is difficult 
to determine whether the impairment of the special sense is due 
to central or to peripheral disease, especially as no change of a de- 
generative character has been demonstrated in the taste bulbs 
or in the middle ear (except waste of the drum) , nor in the sen- 
sory terminals of touch . In making a diagnosis in a senile case, 
we must determine to what extent the symptoms are modified 
by the mental state of the individual. Weakness and the fear 
of falling may produce a gait similar to the gait of spastic paral- 
ysis. Mental dulness may produce lessened appreciation of pain, 
and on the other hand fear of pain may cause excessive sensitive- 
ness, hyperesthesia and even paresthesia. Whenever we must 
depend upon the patient's intelligence for diagnostic information, 
we must endeavor to secure corroboration of the patient's state- 
ments. Incidental complications, i.e., those due to the senile 
disease, and accidental complications, those not due to or 
connected with the primary disease, occur frequently in the 
course of senile diseases. In maturity such secondary diseases 
are often preventable and generally curable. In senility they 
are rarely either avoidable or curable, as they are caused by the 
efforts of co-related organs to maintain harmonious relations 
with the diseased organs, such efforts increasing or perverting the 
functions of the secondary organs and hastening their own degen- 
eration. In the pneumonia of maturity, for example, the action 
of the heart is increased in force and rapidity, thereby increasing 
pulmonary circulation in the unaffected part of the lungs, while 



58 PATHOLOGICAL OLD AGE 

the increased respiration serves to oxygenate the increased 
amount of blood sent by the heart, thereby maintaining the 
circulation of properly oxygenated blood throughout the system. 
If the heart is in good condition it can keep up this rapid pace 
for days without impairment. In pneumonia in old age the in- 
creased activity of the heart, which is already working to the 
limit of its capacity, rapidly exhausts the organ. Death from 
disease in old age is rarely due to the primary disease but to the 
inevitable secondary involvement of vital organs or to general 
physical exhaustion. In making a prognosis we must consider 
not only the disease itself, but the capacity of the co-related 
organs and to what extent they can stand further strain upon 
them. In the treatment of diseases the first as well as the ulti- 
mate aim of the physician should be to prevent the immediate 
cause of death. If there is a persisting cause of the disease which 
can be reached and removed, that should receive attention be- 
fore any treatment itself is instituted. In most cases, however, 
the cause even if persisting cannot be removed and we must 
treat the results. In the great majority of cases the immediate 
cause of death, i.e., the determining factor which causes death, is 
not the disease but either general exhaustion or exhaustion with 
paralysis of the heart. There are other immediate causes of 
death, such as paralysis of the brain, shock, asphyxia, etc., but 
general asthenia and heart failure are the most prevalent and 
the danger that one or the other may set in is present in almost 
every senile disease. The prevention of these two dangers must 
therefore engage the physician's attention from the beginning 
of every disease in old age. Even in diseases like apoplexy, 
cerebral embolism and various toxemias which paralyze the 
brain, cases occur which are prolonged, and secondary con- 
ditions arise which may end in exhaustion or heart failure. 
These dangers should be guarded against as soon as the secondary 
conditions appear. 

A serious difficulty in the treatment of diseases of old age 
is the uncertainty of the action of drugs upon the senile organism. 
We know little of the physiological action of drugs upon normally 
degenerating tissue and we know virtually nothing of the thera- 
peutic action of drugs upon diseased degenerating tissue. Drugs 
which are almost specifics in certain diseases in maturity may be 
ineffectual in similar conditions in senility. Assimilation is 



GENERAL CONSIDERATIONS 59 

changed and drug activity is slower and prolonged and we con- 
sequently get the effects that smaller doses produce. Secondary 
effects are sometimes more pronounced than the primary ones 
and thus we may get unexpected results. In some cases the 
etiological factors influence the action of drugs. In arterio- 
sclerosis due to alcoholism, lead, syphilis, gout, nephritis and other 
diseases, the cure of the disease is accompanied by an improve- 
ment in the condition of the vessels. In such cases the iodides 
will cure arteriosclerosis. If, however, the disease of the 
arteries is not secondary but is merely a simple senile degenera- 
tion, the iodides have no action other than the physiological 
effect of the drug upon the organism. Drugs that have a bene- 
ficial effect upon the kidney of interstitial nephritis have no effect 
upon the senile contracted kidney, although the two resemble 
each other and the senile kidney may present an albuminous 
urine. This may be used as an argument in favor of the state- 
ment that the senile degenerations are essentially different from 
the diseases which present the same morphological features in 
maturity, that for example the arteriosclerosis following syphilis 
is a different disease from the arteriosclerosis which appears 
as the physiological senile change. In some cases where the 
incidental effects of drugs are more pronounced than the primary 
effect, the secondary effect may destroy the primary effect or 
produce other deleterious results. This is well seen in using 
digitalis as a heart tonic in cases where there is arteriosclerosis. 
The drug acts primarily as a heart tonic, increasing the force of 
the contractions. The secondary effect is vasoconstriction 
whereby the lumen of the vessels is diminished. Fortunately 
digitalis in powder or tincture acts slowly, but if the active prin- 
ciple is used hypodermically the action is more rapid, and athero- 
matous cerebral vessels are contracted and at the same time 
they are subjected to the increased pressure exerted by the heart. 
Being unable to stand the strain they rupture and apoplexy is 
the result. Some drugs which are readily absorbed in maturity 
are absorbed so slowly in senility as to be virtually inert. This 
is the case with cinchona and other tannin-bearing drugs. 
The same sometimes happens with gelatine, and gelatine-coated 
pills and capsules may pass through the stomach unchanged. 
Owing to the generally slower assimilation and the constipa- 
tion of old age cumulative effects are more frequent at that 



6o PATHOLOGICAL OLD AGE 

period of life. This is especially true of opium and bella- 
donna which lessen peristalsis in the already weakened in- 
testines. In combining drugs to overcome undesirable by- 
effects the corrective may itself have undesirable secondary 
effects. This is seen in the popular aloin, strychnine and 
belladonna pill in which the belladonna is given to overcome 
the griping effect of the aloin, by allaying the peristalsis, to 
produce which we give the aloin. Incidentally the belladonna 
lessens the intestinal secretions making it still more undesir- 
able in senile constipation. The usual combination of mor- 
phine and atropia is irrational and dangerous in old age as 
it gives a false sense of security in cases where morphine action 
is desired. Morphine beside its primary analgesic effect para- 
lyzes the respiratory centers and to prevent this the atropia 
is added. But morphine acts more rapidly than atropia and 
in the aged where these centers are already weakened, the 
morphine may kill before the atropia has begun to act. 
Herein lies the great danger in giving morphine to the aged. 
If atropia is given a few minutes before we give the morphine 
or if morphine be given per os and a hypodermic of atropia 
is given at the same time morphine can be given in as large a 
dose as in maturity. 

The old dictum that children and the aged cannot stand large 
doses does not hold good when applied to the latter except in 
a few drugs. Many drugs can and must be given in larger doses 
in old age to be effective. In senile constipation, for example, 
we give intestinal peristaltic stimulants, beginning with the 
smallest effective dose. As in time the waste and atony of the 
muscular fibers of the intestines proceed in the process of involu- 
tion, and the peristalsis diminishes, we must gradually give larger 
doses of the stimulant until many times the original dose is 
required to have any effect. Not infrequently an initial dose 
of i/8 grain of aloin must be gradually increased to 2 or 3 grains. 
This is not due to habituation only, for if we change the drug 
the new drug must be given in correspondingly large doses. 
The system does become habituated to a drug, especially in 
old age, but this can be readily overcome by an occasional change. 

As weakened functional activity and secondary effects re- 
sulting therefrom are the most prevalent of the senile ailments, 
tonics and stimulants are the drugs mostly used in senile cases. 



GENERAL CONSIDERATIONS 6 1 

and as functional weakness increases increased doses of the drugs 
must be given. Sedatives and hypnotics are rarely required 
in old age although they are apparently often indicated. When 
they are employed they should be given in the smallest effective 
dose, reduced after the initial dose and stopped entirely as soon 
as the desired effect is obtained. This does not apply to cases 
where the full effect is to be derived from a single dose, as when 
giving an analgesic. In such cases a single full dose, to be 
given with proper precautions for avoiding the incidental effects 
of the drug, is better than repeated small doses. It is often im- 
possible to decide whether the pain from which the patient com- 
plains is real or whether the fear of pain creates the impression 
of pain or produces an oversensitiveness that exaggerates simple 
tenderness into pain. If the disease is usually painful there will 
probably be real pain and morphine is indicated. If it be merely 
oversensitiveness a placebo, preferably one containing aloes, 
quinine or some other disagreeable drug, shoiild be given. 
In many cases the patient will rather stand the pain than take 
the drug and he will often declare that the pain is bearable or 
has entirely disappeared under such treatment. The aged 
frequently complain that they cannot sleep at night and the 
physician is tempted to give a hypnotic. On close questioning 
in these cases it will be found that while the aged patient can- 
not sleep for more than a few hours at night he takes frequent 
naps during the day and the total amount of his sleep in naps, 
dozes and sound sleep may be from ten to fifteen hours out of 
the twenty -four. These cases are hard to handle as the patient 
does not realize that his naps sometimes last for hours, that the 
little doze after reading the papers, etc. (really due to brain 
fag), is sleep, and that he sleeps so much in short stretches during 
the day that the system does not require more than a few hours 
sleep at night. Where there is real insomnia it is better to try 
hot baths, hot drinks, suggestion and other non-medicinal 
measures before resorting to hypnotics. Chloral is useless in 
small doses and dangerous in large doses on account of its 
depressing effect upon the heart. Veronal is perhaps the safest 
hypnotic in old age and if the insomnia is due to mental agitation 
— a frequent cause in the aged — veronal and monobromated 
camphor is a safe and effective combination. The bromides 
are occasionally required to allay nervous excitability. The 



62 PATHOLOGICAL OLD AGE 

sodium salt is preferable to the potassium salt as the former 
contains lo per cent, more of the bromine element and much less 
of the alkali than the latter and is besides not as irritating to 
the stomach. The chronic nervous diseases of maturity seldom 
reach old age and rarely originate in old age. Paralysis agitans, 
the one which occurs most frequently in the aged, is not influ- 
enced by the bromides, while senile tremor is aggravated by 
this class of drugs. 

Drug action is influenced by the mode of administration. 
Drugs should never be given in the form of gelatine-coated pills 
or capsules. Salts given in solution are absorbed quickly but 
if given in powder form, their action depends upon their solu- 
bility. Hours and sometimes days pass before the action of 
insoluble salts like calomel and bismuth is recognized. Drugs 
like arsenic, phosphorus, etc., which may produce local irritation 
in the stomach, should always be given in solution well diluted. 
Where there is danger of cumulative effects care should be taken 
to secure free evacuation of the bowels by active cathartics. 
The gastric and intestinal ferments have little effect in old age 
but predigested food is rapidly absorbed. Drugs used for local 
absorption by inunction must be combined with an animal base, 
either lanoline, lard or sweet butter. Vegetable fats and oils 
are absorbed with difficulty — and mineral bases are not absorbed 
at all by the dry skin in old age. The same applies to liniments. 
They may produce local irritation through friction but an animal 
oil or alcohol is necessary if we want to secure the absorption of 
the drug. 

Hydrotherapy has a wide range of application in senile cases. 
The aged object to the inconvenience connected with entering 
a bath especially if their joints are stiff. They cannot stand the 
shock of a cold bath and even an ice bag may give a dangerous 
shock. Neither can they stand the depletion produced by exces- 
sive diaphoresis. Tepid and warm baths and packs act well in 
every case where a temporary sedative action is desired, and a 
tepid bath followed by friction acts as a stimulant. A warm 
bath followed by inunction will sometimes relieve the stiffness 
of joints due to the senile changes and occasionally the stiffness 
found in various forms of arthritis. 

Electrotherapy has not been sufficiently studied in the aged 
to make a positive statement as to its value. Where there is a 



GENERAL CONSIDERATIONS 63 

partial electrical reaction of degeneration the faradic current 
will produce a temporary stimulation of nerves and muscles, but 
if the reaction of degeneration is complete the faradic current 
has no effect. Mechanotherapy has some appHcation in senile 
cases as massage, friction and passive exercise. It should be 
remembered that excessive activity in muscles hastens their 
degeneration and the increased activity of the heart in forced 
active exercise may cause loss of compensation and rapid ex- 
haustion. The condition of the heart must be the guide in the 
application of mechanotherapeutics in the aged. 

Serotherapy has not been sufficiently employed in the aged 
to determine its value. The diphtheria antitoxin has a more 
profound systemic action on the aged than in childhood and the 
danger from anaphylaxis is apparently greater. This last was 
probably the cause of the unfortunate results obtained from the 
use of Brown-Sequard's testicular extract. 

Treatment at mineral springs is much more in vogue in Europe 
than in America. Mineral waters generally are contraindicated 
in the aged and there are but few diseases in which the benefits 
derived will compensate for their disadvantages. The only 
diseases in the aged which show greater improvement from a 
course of treatment at springs than from home measures are 
cholelithiasis, diabetes and gout. It is probable that the strict 
regimen enforced at the European springs contributes as much 
to the resiilt as the waters themselves, because the same regimen 
at home with the bottled waters does not produce the same 
results. The psychic influence is absent at home and even at 
American springs where the patient can keep in touch with his 
home and business and thus keep up the cares and worries which 
frequently contribute to the disease. 

In the treatment of diseases the author mentions only such 
drugs and measures as he has found to be of service, omitting 
the host of drugs and measures recommended by other 
writers. 

The senile changes bring about vicious circles which increase 
in number and size until every organ and tissue and every func- 
tion is involved. In atheroma the weakened elastic fibers di- 
minish the elasticity of the vessels and the heart must send blood 
with greater force through these vessels to maintain the circula- 
tion. This puts the fibers still further on the stretch, weakening 



64 PATHOLOGICAL OLD AGE 

them more and more. The weakened musctdar fibers of the 
colon permit dilatation of that part of the intestines and feces 
collect in the pouch thus formed, distending the pouch, stretch- 
ing the remaining fibers and further weakening them. Similar 
vicious circles are formed in the stomach and bladder. The 
dilated stomach permits the accumulation of food which fur- 
ther weakens its walls, the dilatation is increased through this 
accumulation of food and gas and this in turn impairs the di- 
gestive power of the organ. 

The dilated atonic bladder holds urine through its inability 
to void it ; this increases the dilatation and permits more urine 
to collect in the larger saccules thus formed, the sacs stretching 
the muscular fibers and weakening them more and more. Owing 
to the atrophy of the lung and waste of the interalveolar septa, 
the aerating surface of the lungs is diminished and the blood is 
improperly oxygenated. The capacity of the blood to carry 
nutrition to the organs is thereby impaired and this includes the 
lungs where the increasing atrophy further diminishes the aerat- 
ing surface. The most pernicious of the vicious circles is formed 
in the heart after the limit of compensatory hypertrophy is 
reached. The heart is now no longer able to overcome the 
impairment caused by diminished expansibility of the arteries, 
dilated veins and weakened valves, its tonicity is lessened and 
it sends blood with less force through the system. The circula- 
tion is slowed and weakened and the elimination of waste and the 
supply of nutrition is slower and thus the nutrition of the heart 
itself is impaired. This further weakens the organ and still 
further weakens the circulation. Retardation of the pulmonary 
circulation causes an accumulation of blood in the right heart, 
producing dilatation and under the combined influences of 
stretching of the cardiac walls, insufficient nutrition and exces- 
sive work to empty overfilled cavities, the heart rapidly degene- 
rates, it becomes exhausted or paralyzed. It requires careful 
discrimination to separate the manifestations of physiological 
senile changes from the symptoms of disease. The treatment of 
the diseases in the aged is still mainly empirical ; every case 
requires individual attention and routine measures based upon 
the same conditions as found in maturity are certain to lead to 
disaster. We must look upon senility apart from maturity and 
its diseases, as sui generis senile diseases. 



CLASSIFICATION OF DISEASES IN OLD AGE 65 

CLASSIFICATION OF DISEASES IN OLD AGE 

There is probably no other branch of science in which nomencla- 
ture and classification are as imperfect as in medicine. Some med- 
ical terms indicate the pathological condition, as chronic paren- 
chymatous nephritis, or acute follicular tonsillitis; some point 
to the etiology, as sunstroke, hay fever, etc. ; some are purely 
symptomatic, as neuralgia, tachycardia, hematemesis; some 
are generic and are applied to several pathological conditions 
which resemble each other in one or more symptoms or in the 
location of symptoms, as rheumatism, pneumonia; some bear 
the name of the physician who first described the symptoms or 
investigated the disease, as Bright's Disease, Addison's Disease, 
Bell's Paralysis; while some terms do not refer to either the 
etiology, pathology or symptoms present. 

In our nosology there is neither order nor system. One 
author follows an alphabetical arrangement beginning with 
abortion and ending with yellow fever. Older writers generally 
classify diseases according to the organs or system of organs in 
which they occur, as diseases of the circulatory system, digestive 
system, etc. Recent authors use an etiological and regional 
classification separating infectious and parasitic diseases from 
the others and dividing the latter according to the system to 
which the affected organ belongs. A more recent classification 
is devised according to the initial cause and divides diseases into 
physical, chemical, animate, mental and nutritional diseases. 
A revolutionary revision of our nomenclature is necessary 
before we can place upon a scientific basis medical terms and the 
classification of diseases, and until this is accomplished every 
classification must be imperfect. 

The basis of the classification employed in this book is the 
relation of the pathological condition to the senile organism. It 
divides the diseases found in the aged into five groups as follows : 

(i) Primary senile diseases, i.e., diseases in which there is 
an increase, decrease or perversion of the ordinary senile anatom- 
ical or physiological changes. 

(2) Secondary senile diseases, i.e., diseases which result 
from the senile changes. 

(3) Modified diseases of old age, i.e., diseases which, when 
occurring in old age are modified by the senile conditions, or 
present features not found in maturity. 

5 



66 PATHOLOGICAL OLD AGE 

(4) Preferential diseases of old age, i.e., diseases which occur 
most frequently in advanced life. 

(5) Diseases uninfluenced by age or are rare in old age. 
Strictly speaking, every disease is influenced by age but the 
diseases of the fifth group are those which do not differ mate- 
rially in etiology, pathology or symptoms from the same dis- 
eases in maturity. 

The first group includes diseases which present abnormalities 
in the normal process of involution. As we have, however, no 
standard of the normal senile conditions and no means of estab- 
lishing a norm, it will be necessary to include the ordinary senile 
degenerations under this heading as nearly all produce discom- 
fort or give rise to secondary pathological conditions. We must 
remember that even slight changes may cause profound func- 
tional manifestations and, on the other hand, there may be exten- 
sive anatomical changes in organs and tissues, without disturb- 
ing their harmonious relations with allied organs and tissues or 
producing symptoms of disease. The true senile diseases may be 
primary, i.e., the cells degenerate through some property in 
the cells themselves, such as has been suggested in the theory 
of tissue-cell evolution, or they may be secondary to arterio- 
sclerosis and then due to malnutrition. These are all included 
under the first group. Changes identical with senile changes 
may be found as the result of other etiological factors. Arterio- 
sclerosis may be due to syphilis and other toxemias, to excessive 
food during prolonged inactivity, to cardiac disease, etc. It is 
possible that future research may disclose some intrinsic differ- 
ence between the tissues degenerating through the normal proc- 
ess of involution and those degenerating from disease. That 
there is some difference is evident from the functional differ- 
ences and from a difference in the action of drugs. 

Diseases of the first group are organic or functional, the 
functional diseases presenting functional perversions for which 
no histological change can be found. Included in the functional 
diseases are senile tremor, senile impotence, senile pruritus, 
senile cachexia, and true senile dementia which is a symptom 
of cerebral atrophy and degeneration. 

Many diseases belong to two or more groups. These will 
be described in the group most closely allied to the senile state, 
as chronic endocarditis which may be primary, secondary or 



SENILE CACHEXIA 67 

modified and which occurs most frequently after middle age, 
and is placed in the first group under degenerations of the heart. 
Senile emphysema belongs to the first group while ordinary 
emphysema which is rare in the aged and does not differ from 
the same disease in earlier life, is omitted. Senile non-infect- 
ious pneumom'a belongs to the second group, while infectious 
pneumonia, whether localized or diffused, belongs to the fifth 
group. In order to preserve continuity of description it was 
found advisable in some cases to describe a disease belong- 
ing to one group with a disease of another group. Doubtful 
etiology may have caused improper grouping. Arrhythmia 
which is probably due to some disturbance of the vagus and would 
therefore belong to diseases of the nerves, is placed in the second 
group under cardiac neuroses and angina pectoris is placed in 
the same class, although it is often a symptom of coronary arterio- 
sclerosis which belongs under primary senile diseases. Senile 
tremor is placed in the first group on the assumption that it is 
a symptom of general debility of the aged and due to cerebro- 
spinal degeneration. 

Where the etiology and pathology of a functional disorder 
is unknown or uncertain it is placed with diseases of a like char- 
acter which can be classified. Other diseases with obscure eti- 
ology and pathology are placed in the fourth group if they occur 
frequently in the aged, or else in the fifth group if they do not 
fit under any other head. 

This classification must be revised as our knowledge of the 
pathogenesis of diseases, like gout, diabetes, cancer, pernicious 
anemia, etc., increases. 

Parasitic diseases, rare tropical diseases and diseases which 
in the aged do not differ from the diseases of maturity have 
generally been omitted. 

PRIMARY SENILE DISEASES 

SENILE CACHEXIA 

Senile Debility 

This term is employed to cover the vitiated condition of the 
senile organism. It includes the lowered functional activity and 
capacity and the obvious manifestations of ageing, which form 
the tout ensemble of senile debility. 



68 PATHOLOGICAL OLD AGE 

Pathology. The Blood. — While neither chemical nor micro- 
scopic examination of the blood of the aged has revealed any ab- 
normal constituent or any marked disproportion of normal con- 
stituents as compared with the blood of younger individuals, 
there is undoubtedly some change in the character of the blood 
of the aged. It has a high percentage of hemoglobin in spite of 
its readiness to part with it to form pigment deposits in the areas 
of degeneration and of passive hyperemia. It has a tendency 
to hold the products of defective metabolism thereby giving 
rise to the diseases of metabolism. Its nutritive value is lowered, 
as its ability to carry nutrition to the organs and waste from the 
organs is diminished. In twelve out of thirteen examinations 
reported by Grawitz, the leucocytes numbered between 4000 and 
8000, and the red cells between 4,470,000 and 5,300,000, the 
hemoglobin percentage was between 90 and no and specific 
gravity between 105 1 and 1060. Notwithstanding the profound 
anatomical change in the senile spleen and in the character of the 
bone marrow, the number of cells are not reduced. The high 
specific gravity is due to a diminution of the watery element 
and the blood of the aged is consequently more viscid than in 
maturity. This favors coagulability with slowed current and pro- 
duction of thrombi and emboli. With the same proportion of 
water as in earlier life the other constituents would be proportion- 
ately reduced and there would be an anemia with deficient cell 
elements and salts. The proportion of chloride of sodium is 
less in the blood of the aged and there is an increase in lime but 
these variations are slight. (Other anatomical and physio- 
logical changes that contribute to the general condition are de- 
scribed under anatomical and physiological changes in old age.) 
The sallowness of the aged is not due to the condition of the blood 
but to deficient surface circulation and consequent changes in 
the integument. In many cases of senile debility the anatom- 
ical and physiological changes are slight and the condition can 
be traced to psychic causes. 

Etiology. — The underlying causes of senile cachexia are the 
underlying causes of ageing. The obvious manifestations are 
due mostly to the anatomical and physiological changes. There 
are, however, some etiological factors that deserve special con- 
sideration. There is a remarkable similarity between the ca- 
chexia of old age and the cachexia of unsanitary life. In the 
latter there is generally insufficient food, in the former there 



SENILE CACHEXIA 69 

is impaired assimilation of food producing the same effect. 
The aged do not get sufficient air into their lungs to completely 
oxygenate the blood c^dng to anatomical changes in the lungs 
and chest wall. Those living imsanitary lives do not get suffi- 
cient pure air into their lungs owing to unwholesome surroundings. 
The effect of insufficient sunshine upon the latter has its counter- 
part in the effect of sunshine upon the weather-beaten skin. 
In both cases there are sallowness, weakened vital functions, 
lessened resistance to disease, slow and incomplete recuperation, 
yet in both the blood count is normal and the cells show no 
abnormalities. It is probable that sunlight itself or its absence 
is a factor in ageing, as those who are deprived of sunlight, 
like miners, persons working in cellars or who work at night, are 
usually sallow or pale and age rapidly, while the withdrawal 
from night work has a rejuvenating effect. 

The general physical weakness that accompanies ageing is 
due to the anatomical and histological changes in the joints, 
the waste and atony of muscle and lessened innervation. In 
the muscles the contractile power is diminished, and the re- 
sponses to stimuli and to the will are slower and less active, 
fatigue sets in more rapidly, is more profound, and recovery 
takes longer. The joints become stiffened; coordination is 
more difficult and it often requires a conscious effort or impulse 
to bring about coordinate movements that have usually been 
performed unconsciously. 

In addition to these senile changes involved in the production 
of senile debility, there is always a psychic factor which may 
be more pronounced than the senile changes. This psychic 
factor may be causative or resultant, aiding in the production 
of senile debility or arising from a recognition of such debiHty, 
but in either case it tends to exaggerate the objective and 
subjective manifestations of this condition. True physical 
debility caused by the anatomical changes in the bones, joints, 
muscles and motor nerves, is progressive, the extent of the weak- 
ness depending upon the extent of the senile changes, and tem- 
porary forced stimulation is followed by more rapid degenera- 
tion. In many cases, however, the debility is apparently 
greater than the anatomical changes would warrant, while there 
is a profound mental depression without marked mental impair- 
ment. In these cases the debility bears a relation to the mental 



70 PATHOLOGICAL OLD AGE 

attitude and little or no relation to the physical condition of the 
individual. In every case of senile debility physical and psychic 
factors are involved, the latter playing but an insignificant part 
in some cases, while in others it may be the main etiological 
factor. 

Symptoms. — Obvious manifestations of senile debility are 
described in the chapter on the Senile State. Aside from the 
changes in the skin and hair, and waste of tissue, the most 
pronounced manifestation is the posture and gait of the aged. 
Owing to anatomical changes in the spinal column and chest 
walls there is an exaggerated dorsal curvature and flattening or 
retraction of the anterior surface of the chest, the weakened 
muscles of the back and neck allow the body to sink and the head 
to fall forward; the shoulders droop, the arms hang, and the 
lower limbs are bent at the hips and knees to maintain equilibrium. 
This characteristic senile stoop does not appear in any disease 
but it may be simulated by the slouch of psychic pseudo-senile 
debility. It is necessary to distinguish between the senile 
stoop and the senile slouch — the former due to the anatomical 
changes and coming on slowly and late ; the latter due to psychic 
causes and coming on rapidly and early. 

The most natural position of an individual is the one involv- 
ing the least physical effort, namely, one permitting complete 
relaxation of the muscles. The ordinary position with head up, 
shoulders thrown back, chest out, the individual standing as 
erect as possible, is the result of effort which long continued 
finally becomes a habit. The child is taught to sit straight and 
to stand straight yet there is always the tendency to relapse into 
slouching position. This tendency overcomes the habit during 
-sleep, under depressing emotion, and in some persons in whom the 
effort to maintain the erect posture has not become a fixed habit. 
The habit is later maintained by a sense of pride in one's appear- 
ance, the erect bearing being more pleasing to the eye, the indi- 
vidual being thereby better able to secure public recognition and 
approval. When an aged person begins to feel the infirmities 
that come with advancing years, the labored breathing upon 
slight physical effort, the fatigue that sets in rapidly, the stiffen- 
ing of the joints and the fact that the usual labors become 
more difficult — he then realizes that he is on the downward 
journey of life. To some this comes as a shock, to others as 



SENILE CACHEXIA 7 1 

the realization of a long anticipated misfortune. It produces a 
mental depression, which is sometimes so profound that ambi- 
tion is lost, there is no longer any pride in appearance and 
the mind is centered upon life itself. Some fear that they have 
not provided sufficiently for their declining years, others that 
they may become a burden upon those who might wish to be 
relieved of this burden. In some cases the loss of sexual virility 
will produce this mental depression. Whatever the cause may 
be, the loss of pride in the carriage or bearing of the individual 
brings about the natural tendency to slouch and the individual 
assumes this position. Worry will hasten the appearance of 
age and in a short time the ageing individual presents the general 
appearance of old age and senile debility. We frequently find 
that an improvement in the mental condition is followed by 
restoration of physical vigor and it is generally noted that 
decrepit persons lose the appearance of decrepitude and gain 
in physical strength upon their admission to a home or asylum 
where they are free from worry. In almost every case where 
senile debility occurs early and proceeds rapidly the psychic 
factor is the main cause. 

The impairment of the special senses, mental impairment, 
intensified emotions, especially fear, minor physical defects, as 
broken-down arches, hyper sensitiveness, etc., must all be in- 
cluded in the conception of senile debility as they all increase the 
helplessness of the individual. These are wilfully exaggerated 
in pseudo-senile debility but appear none the less real to the 
patient. It is difficult to draw a sharp line between this condi- 
tion and senile neurasthenia. The neurasthenic generally main- 
tains his pride in appearance and overcomes the tendency to 
slouch or he may lapse into a slouch from which he can be 
roused with little effort, while it often requires all the skill and 
tact of the physician to rouse the other even temporarily. 

Senile debility is sometimes complicated by senile tremor 
and senile dementia. The tremor is probably due to degenera- 
tion of the spinal cord and will be treated under that head. 
It does not appear in debility of psychic origin except when ac- 
quired through imitation. A slow, progressive senile debility 
and dementia occur normally after the senile climacteric and may 
then simulate general paresis. The latter disease occurs earlier 
in life, there is usually a specific history, a history of convulsions, 



72 PATHOLOGICAL OLD AGE 

delusions of grandeur, rapid mental and physical decay with 
periods of temporary improvement. These features are absent 
in senile debility with dementia. There are several pathological 
conditions marked by tissue waste and debility without other pro- 
nounced symptoms of disease. Schoenlein's senile marasmus — 
an atrophy of the stomach and intestines — may simulate true 
senile debility — or may occur with the latter. In Schoenlein's 
disease there is an excessive amount of feces and lientery, 
while the characteristic stoop is absent unless senile debility 
is present. 

Carcinoma, tuberculosis, marasmus, etc., produce waste of 
tissue and debility, but in these cases the rapid emaciation 
attracts the physician's attention and he looks for a well-defined 
disease. Tuberculosis especially is liable to be mistaken for 
senile debility and its true nature may be overlooked until the 
disease is far advanced. Rapid emaciation with debility and 
without other marked symptoms or with an afternoon rise in 
temperature points to tuberculosis. 

Treatment. — The treatment of senile debility includes med- 
ical, psychic and hygienic measures. 

The medicinal measures have for their object, (i) the func- 
tional stimulation of muscles and nerves, (2) the relief of the 
stiffness of the joints, (3) improvement of the mental attitude, 

(4) relief of minor ailments associated with senile debility, 

(5) general tonic treatment. 

Phosphorus, strychnine, and arsenic meet the first, third, 
and fifth of these indications. Arsenic increases bodily vigor, 
stimulates the appetite, favors constructive metabolism and 
improves the general physical condition of the individual. It 
is the most valuable tonic for the aged, but it is a treacherous 
drug, the limit of tolerance being sometimes reached in two or 
three months and at other times two or three doses given in 
twelve-hour intervals to the same person will produce a cumula- 
tive toxic effect of the combined dose. Strychnine is a powerful 
nerve stimulant, having, however, the serious drawback that 
it increases heart action as well. If there is cardiac hypertrophy 
— the usual condition of the heart before decompensation — it is 
contraindicated. When there is no contraindication to its use it 
can be combined with arsenic as strychnine arsenate in doses of 
i/ioo grain. The dose of the arsenic in this salt is small and 



SENILE CACHEXIA 73 

there is no danger of rapid toxic effect. If there is an objection to 
strychnine, the arsenic should be given alone or with phosphorus, 
in doses of 1/40-1/20 grain of the arsenic trioxide or six minims 
of Fowler's solution twice daily. As soon as cramps or pain in 
the stomach, a distaste for food, or swelling under the eyelids 
appear, the drug must be stopped. Phosphorus is a mental 
stimulant, nerve tonic and aphrodisiac which has no cumulative 
effect, and no reaction; its action is prolonged and it can be 
discontinued without detrimental effect. It increases mental 
activity and produces a sense of well being, rousing frequently a 
desire for increased physical exercise. It can be given in doses 
of i/ioo grain of the ordinary phosphorus, or 2 grains of the 
amorphous, non-toxic red phosphorus. Lecithin, notwithstand- 
ing its organic phosphorus content, does not produce the same 
effect as the inorganic drug. 

Phosphorus should be given until there is a noticeable im- 
provement in the patient's mental attitude. Whenever mental 
depression appears again its use must be resumed in an increased 
dose. 

Opium and its preparations are active cerebral stimulants 
in small doses, but the effect soon wears off and there is danger 
of habituation. They are not mental restoratives, for the reason- 
ing power acts vicariously; ideas are more florid, the imagina- 
tion is stimiilated, but memory is not improved, as neither the 
receptive nor retentive power is strengthened. Cocaine is a 
cerebral stimulant and produces a sense of well being but it is 
always dangerous in the aged especially so in the arteriosclerotic. 
Coffee or caffeine can be used as a general stimulant without 
danger. 

The treatment for stiffening of the joints is given in the 
chapter on Arthrosclerosis Senilis and the treatment of the 
minor ailments is given under their various headings. 

Psychic measures are most important in pseudo-senile 
debility and are of some service in the true senile debility. The 
old soldier hobbling along on Decoration Day makes a firmer 
step, walks erect and becomes spry and lively as he passes the 
reviewing stand. Flattery has a more permanent rejuvenating 
effect, especially flattery from a young person of the opposite 
sex. Association with younger persons on the plane of com- 
panionship and especially marriage with a younger person will 



74 PATHOLOGICAL OLD AGE 

do more to dispel the feeling of mental and physical debility 
than any medical measures. The ancient Romeo who goes 
courting becomes young in feelings and forces himself to both 
actions and looks to correspond with his mental attitude. 
Where the psychic factor causing the general weakness was 
worry, relief from this worry will relieve the debility. This ac- 
counts for the improvement of aged persons immediately upon 
a change of environment — interesting sights that do not confuse 
or fatigue, old familiar, lively airs, the pursuit of a harmless 
hobby; anything that will tend to divert the mind from the 
body and from death will have a beneficial effect upon them. 
The benefit derived from the freedom from worry upon en- 
tering a home for the aged, is soon dissipated when the aged 
person finds his associates complaining of their petty ills and 
when he sees these associates dying. The aged person should 
have a pleasant young companion, preferably of the opposite 
sex, constantly around him. 

The hygienic treatment will be given in the chapter on 
Hygiene. 

SENILE ARTERIOSCLEROSIS 

Arteriosclerosis is the most frequent and in its consequences 
the most important of all senile degenerations. Faulty nomen- 
clature and a failure to differentiate between different forms of 
arterial degeneration are responsible for the many misconcep- 
tions concerning this condition which in its milder form is 
natural and normal in old age. 

The terms arteriosclerosis, atherosclerosis, atheroma, arterio- 
capillary fibrosis, arterial sclerosis, atheromatosis, arteritis de- 
formans, endarteritis nodosa, endarteritis deformans, periar- 
teritis, have all been used interchangeably or to designate one 
form or another of arterial degeneration, thereby creating con- 
fusion. Bishop introduced the term cardiovascular disease to 
cover a clinical syndrome including disease of the heart and of 
the blood-vessels, arteriosclerosis and the co-related conditions 
of autointoxication, neurasthenia, kidney degeneration, etc. 

The term is unfortunate since it includes many conditions 
which differ in association, pathology and symptoms, hence 
it does not represent a definite entity. 



SENILE ARTERIOSCLEROSIS 75 

The term senile arteriosclerosis is applied to a form of arterial 
degeneration which is part of the process of involution , not due 
to antecedent disease, is progressive and incurable. A pure 
senile arterial degeneration uninfluenced by any other factor than 
the underlying cause of ageing is hardly conceivable. It will 
therefore be necessary to describe other forms in order to under- 
stand the ordinary degeneration found in the aged. Arterio- 
sclerosis is divided, (i) as to extent, into circumscribed and diffuse 
or general, the former involving one or more circumscribed areas, 
the latter involving to some extent most or all of the arteries 
of the body; (2) as to location, aortic, cerebral, coronary, radial, 
etc., depending upon the vessel involved; (3) as to etiology, 
physiological as occurs in the normal process of involution, 
presenile when the process is normal but hastened, and patho- 
logical when due to disease ; (4) as to pathology, inflammatory 
when beginning as an endarteritis, mechanical when beginning 
by loss of tonicity of the muscular coat, and nutritional when due 
to interference with the nutrition of the vessel through inflam- 
mation or blocking of the vasa vasorum; (5) as to prognosis, 
temporary and permanent, the former curable, the latter 
incurable; (6) primary or secondary, the latter when following 
and due to another disease. 

Etiology. — The basic cause of physiological or senile arterio- 
sclerosis is the basic cause or causes of ageing. Any of the 
fundamental causes of senile involution, whether ascribing the 
initial changes to the blood, to the blood-vessels or to the cells 
can be made to fit the etiology of senile arteriosclerosis. 

The prevalent view of German physicians favors Thoma's 
histo-mechanical theory and loss of tonicity of the muscle 
fibers. In France and America Metchnikoff's autointoxication 
theory with endothelial irritation and inflammation is favored. 
A more recent theory ascribes the basic cause to hyperactivity 
of the adrenals whereby a contraction of the arterioles is pro- 
duced and consequently the vasa vasorum receive a diminished 
supply of blood and the larger vessels are insufficiently nourished. 
While the senile changes in the blood-vessels can be explained 
by the cell-evolution theory, it has not been verified and it is 
presented here as a possible cause, acting alone or in combina- 
tion with other causes. The main objection to Thoma's theory 
is the fact that in most cases endarteritis or degeneration due to 



76 PATHOLOGICAL OLD AGE 

insufficient nutrition occurs before the appearance of muscle 
atonicity, as evidenced by vascular dilatation. The objections 
to the theory of autointoxication as the basic cause in normal 
degeneration are that feeding animals with sterile food causes 
death, that meat is supposed to be the principal source of 
alimentary autointoxication yet vegetarians have arteriosclerosis 
and the amount of meat consumed bears no relation to the extent 
of the degeneration, and that autointoxication goes on almost 
from birth. It is undoubtedly a very potent contributing factor 
but it cannot be accepted as the determining cause. A deter- 
mining or basic cause must produce like results under like 
conditions and such results must always be traceable to such 
cause. Applying this test to the autointoxication theory we 
find that the absorption of the products of intestinal decomposi- 
tion does not always produce arteriosclerosis nor can we trace 
every case of arteriosclerosis to this cause. 

The discovery of Josue that the injection of adrenalin 
in rabbits produces arterial degeneration is the basis of the theory 
of adrenal hyperactivity. The adrenal secretion has a selec- 
tive property upon the arterioles, contracting them thereby di- 
minishing the blood supply to the vasa vasorum which arise from 
the arterioles. This would seem to indicate that the disease 
arising from adrenal hyperactivity has a causal relation with 
increased blood pressure. Adler has shown that the disease pro- 
duced experimentally is not identical with arteriosclerosis in 
the human subject, that other substances can produce the same 
lesions, and that the injection of adrenalin does not always pro- 
duce arterial degeneration. L. Braun, using adrenalin and 
amyl nitrite, produced the lesion in the aorta without increased 
blood pressure and a like result was obtained by the use of other 
substances which have little or no effect upon the blood. It is 
evident that the action of adrenal secretion when in excess is 
not due to its blood-raising property but to its toxic effect. 
It has been shown that nicotine will stimulate the adrenals and 
this has been advanced to explain the prevalence of the disease 
in tobacco smokers. It is, however, a question whether the 
effect of tobacco is due to the action of the poison upon the adre- 
nals, or upon the vasomotor centers or to the irritant action of 
the nicotine upon the vessels themselves. The divergence of 
opinion based upon contrary results of similar experiments can 



SENILE ARTERIOSCLEROSIS 77 

be explained only by the failure to recognize different local and 
general conditions. It is probable that numerous factors are en- 
gaged in the etiology of senile arteriosclerosis as well as in most 
pathological forms. There is the underlying cause of senile invo- 
lution and contributing thereto are inherent factors as heredity 
and muscular activity, and acquired factors as smoking, exces- 
sive meat eating, abuse of alcohol, sexual excesses, etc. The 
influence of heredity cannot be satisfactorily explained and it 
would serve no purpose to dilate upon the many theories that 
have been advanced to account for hereditary influence. The 
effect of muscular activity has been explained by the presence 
in the blood of the toxins produced by muscular activity, by 
overstimulation of the adrenals, by irritation and inflammation 
of the endothelium through the greater force with which the 
blood is sent from the heart, and by more rapid exhaustion of 
the muscular fibers of the vessels. 

The modus operandi of autointoxication in the production 
of arterial degeneration is unknown. There may be direct 
irritation of the arterial endothelium, irritation of the vaso- 
motor centers, of the heart or adrenals, impairment of the pabu- 
lum, or the formation of minute emboli which partially block the 
arterioles. The influence of alcohol is a moot question. Edgren 
found 25 per cent, of his cases traceable to alcoholism, and Herz 
obtaining the opinions and results of observation from about 
800 physicians found that over half gave alcohol as a factor. 
On the other hand, many physicians reported that arteriosclero- 
sis was very rare in some regions where alcohol was habitually 
used even by women and children. The disease is found among 
total abstainers, among vegetarians and among persons who 
never smoke, while many aged persons with a comparatively low 
blood pressure and soft arteries drink, smoke and eat meat 
daily. 

Weil's theory may be mentioned here as there are some 
favorable reports of a method of treatment based upon this 
theory. Weil found that while the normal daily elimination of 
CaO through the kidneys was .39 grams, in over 50 per cent, of 
his arteriosclerotic cases the elimination was less than .2 grams 
and in no case did it reach the normal notwithstanding abundant 
lime introduction. The conclusion is that there is an excessive 
lime retention with consequent disproportion of salts in the 



78 PATHOLOGICAL OLD AGE 

blood. Lime deposits in the vessels occur late in the disease and 
this theory does not explain the early degenerative process. It 
opens, however, a new field for speculation. As Weil's obser- 
vations indicate perverted metabolism similar to the changed 
metabolism in gout and as late gout is marked by pathological 
deposits of calcareous matter in joints and other tissues while 
late arteriosclerosis is marked by similar deposits in the arterial 
walls may there not be the same metabolic disturbance under- 
lying both diseases? The clinical picture differs according to 
the tissues involved. If the same perversion of metabolism — by 
which lime is retained in excess of the needs of the system and 
deposited in abnormal locations — is responsible for both gout 
and arteriosclerosis, the same treatment ought to be effective in 
both. The causes of arteriosclerosis can be placed under one 
of three heads : causes acting by irritating the lining membrane, 
or acting primarily upon the media, or acting primarily upon the 
vasa, vasorum either through inflammation or through dimin- 
ished blood supply from contracted arterioles or increased 
viscosity of the blood. 

Nervous, mental and emotional stress is an incidental 
factor acting probably through the vasomotor centers. Most 
other causes are toxemic, either bacteria, or endogenetic toxins, 
products of disturbed metabolism, or chemicals introduced from 
without. Their mode of action has been suggested under 
autointoxication. 

Arteriosclerosis occurs most frequently in brain workers, 
in the well-to-do class, in women before the fifty-fifth year, 
and in men after that age. 

Syphilis and lead produce a degeneration of the arterial 
walls so radically different from the ordinary senile arterio- 
sclerosis that the conidtion resulting from these causes should 
receive a special designation such as syphilitic degeneration or 
lead degeneration of the arteries. They act by irritating the 
lining membrane. 

Pathology. — The early pathology of arteriosclerosis depends 
upon the etiology and is determined by the location of the initial 
lesion. This may be in the intima, media or vasa vasorum. 
If the disease is due to a cause producing local endothelial irri- 
tation the earliest change is a multiplication of cells at the point 
of irritation. Patches of endothelium thus become thickened 








E h// ! ? '■ ' ' 



:v^7;#^* 



fA.- 






Obliterative Endarteritis. (T/ze tissue from which dr awing was made was 
removed from near a cancer of the face, and prepared in the laboratory of the 
Jefferson Medical College Hospital by Dr. Thomas Leidy Rhoads.) i-inch objec- 
tive, i-incli ocular. Specimen fixed in corrosive sublimate, infiltrated with par- 
afiEin, stained mth hematoxylin and eosin, and mounted in balsam, a. Adventitia, 
h. Media, c, c. Elastic lamina, d. Irregular mass of organizing tissue superim- 
posed on and replacing the intima. The gross specimen was hard, cord-like, but 
not nodular. 



SENILE ARTERIOSCLEROSIS 79 

and soon undergo granular and fatty degeneration. The patch 
becomes transformed into a yellow, opaque nodular mass con- 
taining cholesterin, fatty granules and crystals, and is separated 
from the blood current by a thin pellicle. This atheromatous 
mass diminishes the lumen of the vessel. In some cases the 
patch contains little fat but instead a mass of dark brown gran- 
ules and broken-down cells. Later, calcium deposits in the 
patches, first forming, in combination with the fat, calcium 
soaps. These break up, the calcium combines with carbonic 
acid and phosphoric acid radicles derived from the blood and 
thus the insoluble calcium carbonate and calcium phosphate are 
formed. The degeneration proceeds outward involving the 
connective tissue, which hypertrophies, and the elastic and mus- 
cular tissues, which waste. In most cases after the thickening 
of the endothelium, whereby the caliber of the vessel is dimin- 
ished, this or some other cause interferes with the free passage of 
blood through the terminal vessels, the vasa vasorum receive 
insufficient blood supply and the main vessel is consequently 
insufficiently nourished. This causes waste of the highly organ- 
ized muscle fiber and hyperplasia of connective tissue which re- 
quires less blood supply than the muscle structure. Still later, 
calcareous deposits occur in the outer coat, the deposits occurring 
in plaques over the patches of the inner coat or are diffused 
through the substance of the vessel. This is the usual course 
in circumscribed arteriosclerosis and forms the inflammatory 
type of the disease. The second or mechanical degeneration 
begins in the media. If there is loss of tonicity of the muscular 
fibers through overstretching, the vessel becomes tortuous and 
dilated and the current is slowed. This is followed by a compen- 
satory thickening of the intima through proliferation of the sub- 
endothelial connective tissue. The muscular fibers having lost 
their elastic property become changed and they degenerate, 
their place being taken by fibrous connective tissue which also 
displaces the elastic fibers. Lime deposits occur late and are 
diffused. This is the usual process in senile arteriosclerosis. In 
small vessels the caliber may be diminished through overgrowth 
of the intima. In the third or nutritional type of degeneration 
there is more or less rapid degeneration of the media through 
insufficient nutrition. A diminished blood supply causes rapid 
waste of muscle and elastic fiber leaving minute cavities called 



8o PATHOLOGICAL OLD AGE 

atheromatous abscesses and allowing small aneurysmal sacs to 
form. The cavities later become filled with granular and fatty 
debris. An increase in the connective tissue now takes place 
and the walls of the vessel are in spots thickened, in other spots 
thin and liable to rupture. Calcareous deposits occur early in 
the broken-down cavities. 

In the condition described by the French as Aortite aigue, 
acute aortitis, there is an inflammatory condition of the vessel 
beginning at the point where the blood sent out from the left 
ventricle impinges upon the aortic wall, spreading downward and 
along the arch. 

Huchard divides arteriosclerosis into four stages, an arterial 
stage, cardioarteriosclerotic stage, mitroarterial stage and cardi- 
ectatic stage. In the first stage, called also presclerotic stage, 
the toxins in the blood irritate the intima and by extension to the 
media cause the vessels to contract thus diminishing their 
caliber. The heart must now act with greater force to send the 
blood through the contracted vessels. In the second stage the 
organic changes begin in the arterial walls and heart. These 
are followed by nephritic changes and cerebral disturbance. In 
the third stage the heart becomes dilated and the blood pressure 
is lowered. In the last stage the secondary results of cardiac 
dilatation appear in the kidneys, lungs, liver, etc. There is 
edema of the extremities, abdomen and lungs and passive con- 
gestion of the liver. 

Few cases of arteriosclerosis follow these stages as presented 
by Huchard. In senile cases the diminished supply of blood 
may produce degenerative changes in the kidneys, liver and 
lungs while the heart shows little alteration and no loss of 
compensation. 

Symptoms. — The earliest subjective symptoms are referable 
to the organs and tissues affected by the impaired functions of 
the degenerated vessels. The vessels themselves give no early 
symptoms. When the disease is far advanced the vessel feels 
hard, tense, often nodular and where visible it appears tor- 
tuous. Long before these objective manifestations appear, 
the subjective symptoms pointing to organic disorder will call 
attention to the disease. The symptoms and the lesions do not 
always correspond, extensive areas of arteriosclerosis having 
been found after death which gave no evidence during life, and 



SENILE ARTERIOSCLEROSIS 8 1 

in some cases symptoms usually associated with some form of 
arterial degeneration made life miserable yet no pathological 
condition to account for them could be found upon autopsy. 

The earliest sign of arteriosclerosis is usually increased blood 
pressure but we must remember that high blood pressure and 
arteriosclerosis are not synonymous, and that we often find 
arteriosclerosis with low blood pressure. 

The normal systolic blood pressure in old age can be approxi- 
mately determined by adding the age to one hundred m.m. and 
allowing a leeway of about 5 per cent, above and below the sum 
of the two. Many persons have a habitual high pressure with- 
out other sign of arterial degeneration. This is found in athletes 
and those who do hard physical labor. The blood pressure is 
raised in many diseases and by many drugs, without impair- 
ment of the vessels. The diseases and drugs which raise the 
blood pressure may produce arteriosclerosis if their action is main- 
tained long enough. Indicanuria is not a symptom of arterio- 
sclerosis but it is frequently found in that disease and whenever 
it is found in an aged individual it is almost certain to be ac- 
companied by high blood pressure and other signs of arterial 
degeneration. Bishop has shown that in neurasthenia there is 
usually a low blood pressure though arteriosclerosis may be 
present. It is probable that the increased blood pressure in 
nephritis and gout is due to the increased viscosity of the blood 
whereby it passes through the capillaries with greater difficulty 
and the heart action must be increased to overcome the in- 
creased peripheral resistance. The retention of lime in the aged 
increases the viscosity of the blood and this contributes to raise 
the blood pressure by increasing the peripheral resistance. In 
addition to this, there is usually a hypertrophied heart, apart 
from the atonicity of the vessels. A diminished amount of 
blood in the arteries has a counteracting influence but not enough 
to overcome the causes of increased blood pressure. When de- 
compensation sets in the blood pressure falls. 

In some cases the earliest sign of arteriosclerosis is seen in the 
tortuous retinal vessels. Occasionally the normal difference in 
the pulse rate when standing and when in the recumbent posi- 
tion is not maintained. If the pulse is more frequent in the 
recumbent position the disease is well advanced. The disease 
may be suspected if the rate when standing is less than six over 

6 



82 PATHOLOGICAL OLD AGE 

the pulse rate when lying down. There are numerous vague 
symptoms of nervous origin which have been considered sug- 
gestive of approaching arteriosclerosis and their presence has 
given rise to the opinion that there exists a presclerotic stage 
of the disease. When we remember that the normal degenera- 
tion is slowly progressive, that there is a progressive increase in 
blood pressure from birth and that the normal condition is a 
disease condition only in the sense that it produces discomforts 
we will realize the impossibility of determining at what point 
senile arteriosclerosis becomes pathological, or of defining the 
so-called presclerotic stage. Such symptoms as headache after 
smoking, palpitation upon exertion, sensory disturbances, etc., 
are early manifestations of localized arteriosclerosis; they may, 
however, be due to other conditions than arterial degeneration. 
A fairly reliable premonitory sign of diffuse arterial degeneration 
is an intermittently high blood pressure, the pressure rising 
higher from ordinary causes producing temporary tension than 
the cause itself would warrant . In a typical case a man aged sixty 
had a normal systolic pressure of i6o mm. upon arising. Walk- 
ing up one flight of stairs raised the pressure to 190 and half an 
hour afterward the pressure dropped to 150. There was no 
other sign of cardiac or vascular disease but six months later the 
man had a stroke of apoplexy. 

For the purpose of systematizing the manifold symptoms 
of regional arteriosclerosis the disease will be divided into central, 
including the heart and large vessels; visceral, including the 
viscera and the vessels supplying them; and peripheral arterio- 
sclerosis, including arterioles and the peripheral vessels. 

Senile endocarditis and the various cardiac lesions due to 
arteriosclerosis ought to be included in the central group but 
will be described separately. 

Aortic Arteriosclerosis. — Aortic arteriosclerosis is the most 
frequent of the arterial degenerations. The vessel is dilated, its 
expansibility is diminished, the muscular coat is replaced by 
fibrous tissue and there are fatty or calcareous plaques on the 
inner coat. It gives no distinctive symptoms. Occasionally 
an increased area of dullness can be demonstrated, there is some- 
times a systolic murmur over the vessel and there may be jugular 
pulsation. If the arch is involved the pulsation can sometimes 
be felt behind the suprasternal notch. There may be a dif- 






Arteriosclerosis of 
Abdominal Aorta. 
(Satterwaite Medical 
Record, May 14, 1910.) 



Aorta, Opened, Showing Different Types of Atheroma, 
(From Coplin's "Manual of Pathology.") The surface is 
most extensively altered by infiltration, degeneration, and 
necrosis. INIany of the necrotic areas are calcified and could 
be fractured by bending. A, A, A. Elevated obstructing 
patches of atheroma surrounding exit points of small 
branches. B, B. Linear atheroma. 



ps^/r\ '>.'^^ 



^~s. 




Arteriosclerotic DiseabC oi the Coronar> AiLci) Gi\ing Rise to 
Progressive Obliteration of its Lumen. (From Coplin's "Manual 
of Pathology.") Section taken from sclerotic periventricular branch 
shown in Fig. 230. The elastic lamella are fragmented, the endothe- 
lium has proliferated, and a forming thrombus is rapidly occluding the 
vessel. A. Forming thrombus covered at most points by endothe- 
lium. B. Channel through thrombus with partial wasting of ad- 
jacent vessel wall. C, C. Transverse section of muscle-fibers, show- 
ing fragmentation and retraction from the myocardial skeleton. D. 
Unusually conspicuous, apparently swollen elastica; the same change 
can be seen in many parts of the field. The fine stipple effect in the 
lower part of the figure, and especially marked in the lower right, is 
due to transverse sectioning of elastic fibers. 



M^^ 









^l 










Coronary Artery, Sho\ving Arterial Sclerosis. (From" 'Coplin's 
"Manual of Pathology.") ^. Adventitia. 5. Media. C. Intima. D. 
Degenerating newly formed tissue which at E shows advanced softening. 



SENILE ARTERIOSCLEROSIS 83 

ference in the character of the carotid pulse on the two sides. A 
difference in the character of the radial pulse on the two sides 
may be due to aortic, subclavian, brachial or radial arterio- 
sclerosis. 

Acute Degenerative Aortitis. — This occurs most frequently in 
plethoric individuals sho\^dng symptoms of cardiac hypertrophy, 
palpitation and dyspnea. The symptoms come on suddenly 
with intense dyspnea resembling a severe attack of spasmodic 
asthma, a pain over the aorta, anginal in character, during the 
attack, and a constant pain or ache between the attacks. In 
some cases the first attack destroys life, more often the patient 
succumbs after several attacks. 

Aortic Aneurysm. — ^Aortic aneurysm m^ay appear as a mani- 
festation of senile arteriosclerosis, although it occurs more fre- 
quently as a result of syphilitic infection. Occurring as a primary 
disease it is generally spindle shaped, the dilatation involving 
all the walls of the vessel. Its progress is slow when due to 
senile arteriosclerosis, the dilatation proceeding but little faster 
than the dilatation of the rest of the vessel, and the walls of 
the aneurysm continue to harden with the walls of the aorta 
above and below it. For this reason it never attains the 
size of the syphilitic aneurysm nor of the aneurysm due to 
traumatism or sudden strain, and the pressure symptoms that 
mark the other forms are seldom pronounced. The lesion is 
most frequently at or just above the root of the ascending por- 
tion of the aorta and is recognized more often by the physical 
signs than by pressure symptoms. There is usually a palpable 
occasionally a visible, pulsation over the site of the dilatation, 
dullness on percussion and a systolic murmur carried upward to 
the neck. When the arch is involved the signs are most pro- 
nounced behind and to the left of the upper part of the sternum, 
and when in the descending portion the signs are most pronounced 
in the interscapular space. Bretschneider reported a case of 
sclerosis of the arch of the aorta which presented as one of the 
symptoms, an intermittent dyskinesia with paroxysms of pain 
along the arm, numbness and loss of contractility of the muscles 
of the entire upper extremity. 

Coronary Arteriosclerosis. — Sclerosis of the coronary arteries 
has no pathognomonic symptoms. The only symptom which is 
constantly associated with this condition is angina pectoris, but 



84 PATHOLOGICAL OLD AGE 

this symptom may be due to other causes and coronary sclerosis 
has been found after death which gave no symptoms during 
life. As one result of coronary disease is malnutrition of the 
heart with consequent muscular degeneration, the symptoms of 
such degeneration whether fatty infiltration, fatty degeneration, 
myofibrosis or brown atrophy, point to coronary sclerosis. The 
symptoms associated with angina pectoris will be given in de- 
scribing this disease under cardiac neuroses. The presumptive 
diagnosis based upon cardiac asthma, cardiac degeneration and 
angina pectoris amounts almost to a certainty. 

Arteriosclerosis of the Pulmonary Artery. — Arteriosclerosis of 
the pulmonary artery is rare and the diagnosis is difficult. There 
is generally a history of infection with mitral stenosis or aortic 
insufficiency and arteriosclerosis of the aorta. The symptoms 
are cyanosis without dyspnea or edema, and pulmonary hem- 
orrhage. The physical signs are, an area of dullness about the 
upper left margin of the sternum sensitive to pressure and per- 
cussion, cardiac dulness increased to the right, the diastolic 
thrill and the presystolic murmur of mitral stenosis above and to 
the right of its usual location. The condition may be diagnosed 
by radiography. 

Arteriosclerosis of the Abdominal Aorta. — ^A positive diagnosis 
of sclerosis of the abdominal aorta can be made only when the 
abdominal walls are thin and the artery can be felt. It may be 
possible then to feel nodiiles or areas of hardness, or irregularities 
in the impulse given to the fingers by the pulsation of the vessel. 
There are no pathognomonic symptoms but the disease may be 
suspected when there are other symptoms and signs of a general- 
ized arteriosclerosis and vague, painful sensations in the ab- 
domen increasing at times to agonizing crises. 

Cerebral Arteriosclerosis. — Cerebral arteriosclerosis gives so- 
matic and mental symptoms. The earliest of the somatic 
symptoms is a dull frontal headache most severe upon arising 
and passing off in the course of the day. This headache is due 
to a passive hyperemia produced by the recumbent position, 
which passes away when the patient is erect. In some cases the 
cerebral hyperemia, caused by the recumbent position and re- 
lieved by the erect posture, is replaced toward evening by a 
gradually increasing cerebral anemia until a feeling of faintness 
compels the patient to lie down. Dizziness and vertigo are 




Atheroma of Brachial Artery. (Pic and Bonnamour.) 




Radiogram of Arteriosclerosis of Internal Iliac Artery. (Courtesy of Louis Gregory 
Cole, M. D. New York.) 



SENILE ARTERIOSCLEROSIS 85 

early symptoms. There is a momentary feeling of fulness as 
though a gush of blood came up from below, went whirling through 
the head then just as suddenly dropped down again. This is 
accompanied by a flushing of the face, roaring in the ears, dim- 
ness of vision and dulness of intellect. The whole syndrome 
lasts but a moment and disappears completely. As the disease 
progresses the symptoms become more frequent and prolonged 
and during the attacks the patient becomes unsteady on his feet 
and may fall. Numbness, muscular twitching, weakness of the 
limbs, trembling and disturbances in articulation may occur. 
Insomnia is a frequent accompaniment. The mental disturb- 
ances are alternating depression and excitability, illusion and 
dementia. The illusions are not insane illusions but perverted 
perceptions which the patient recognizes as such. Thus asclero- 
sis of the retinal vessels more marked on one side may give two 
different visual impressions, and an object may appear double, 
distorted or with a halo or shadow about it. There may be 
similar auditory perversion producing confused sounds. The 
patient knows that these are illusions and ascribes them to dis- 
ease of the eye or ear. More serious are the mental confusion 
and delusions which occur when the patient becomes excited as 
these may persist and give rise to anxiety and other psychoses 
followed by melancholia and dementia. 

In the severer forms of cerebral arteriosclerosis there may 
be transient paralysis, aphasia, hemianopsia, mental aberra- 
tion, etc., passing away in a few hours. There is always 
danger from rupture of a minute vessel, producing apoplexy 
or from thrombus or embolus with consequent rapid cerebral 
degeneration. 

Ear Symptoms. — The ear symptoms begin in a unilateral, 
later bilateral, tinnitus, followed by slight and progressive deaf- 
ness, loss of air and bone conduction, dizziness and auditory 
illusions and hallucinations. 

Eye Symptoms. — The arteriosclerotic eye shows tortuous reti- 
nal vessels, and occasionally retinal hemorrhages due to in- 
creased tension in vessels in which there is an endarteritis. There 
may be an embolus or thrombus of the central artery if there is 
cerebral arteriosclerosis and then the vessels are anemic. Usu- 
ally there is a retinitis if the arteriosclerosis is associated 
with albuminuria, embolism or thrombus if associated with 



86 PATHOLOGICAL OLD AGE 

cerebral or cardiac disease and atrophic choroiditis if associ- 
ated with disease of the liver. 

Abdominal Arteriosclerosis. — Degeneration of the abdominal 
vessels may be suspected when there are signs of diffuse arterio- 
sclerosis and symptoms of visceral disturbances, non-inflamma- 
tory in character with progressive impairment of function. The 
symptoms of abdominal arteriosclerosis are more marked in al- 
lied organs and tissues than in the rest of the body and as the 
heart is usually the first to be affected by impaired circulation, 
the kidneys are soon involved. The kidney is frequently found 
degenerated yet the renal artery is not affected. (This will be 
taken up under senile degeneration of the kidney.) 

Gastro-intestinal Arteriosclerosis. — The symptoms of gastro- 
intestinal arteriosclerosis are manifold and appear to be due to 
impaired nutrition of the organs and irritation of the abdominal 
sympathetic nerves. We thus get two sets of symptoms, 
functional impairment and nerve irritation, the latter probably 
caused by some toxic substance in the blood. 

The early diagnosis of this condition is difficult, as the organs 
affected appear to be the original seat of disease until other symp- 
toms and signs of arteriosclerosis are found. There is usually ab- 
dominal pain about the umbilicus, at first paroxysmal, later 
continuous. The digestion is slowed and there is a feeling of 
oppression in the stomach for several hours after eating. This is 
due to dilatation and atrophic catarrh of the stomach. 

The intestinal symptoms are constipation, flatulence, met- 
eorism, occasional watery or bloody diarrhea, beginning without 
apparent cause, lasting for a few hours there followed by con- 
stipation, sharp pains in the right hypochondrium, neuralgic but 
not colicky, occurring spasmodically and frequently at night. 
The mesenteric arteries are occasionally atheromatous but they 
give no pathognomonic symptoms. Lagane describes an arterio- 
sclerotic syndrome of the intestines but the symptoms include 
many that are clearly due to other pathological conditions. 

Some of the symptoms of abdominal arteriosclerosis resemble 
symptoms of tabes, colic, appendicitis, lead poisoning, nervous 
dyspepsia, neurasthenia, or other neuroses. In nearly all doubt- 
ful cases the etiological factors will clear up the diagnosis. 

Hepatic arteriosclerosis. — While the liver generally shows 
atrophic degeneration due to malnutrition it gives no signs of this 



SENILE ARTERIOSCLEROSIS 87 

condition except in diminished bile supply, the bile containing 
more cholesterin and sometimes producing the symptoms of 
cholecystitis and cholelithiasis. These will be taken up 
separately. 

The pancreas and spleen, on autopsy, are often found de- 
generated, yet give no clear symptoms during life. 

Ortners Syndrome. — Ortner describes a symptom complex 
referable to the stomach, intestines, heart and lungs. These are 
distress after eating, distention of isolated section of the bowels 
with intense spasmodic pain, cyanosis and dypnea. He calls 
the disease " Dyspragia intermittens angiosclerotica intestinalis." 

Arteriosclerosis of Spinal Vessels. — The dominant symptoms of 
arteriosclerosis of the spinal vessels are those of chronic myelitis, 
occasionally with symptoms of multiple sclerosis, syringo- 
myelia, tabes dorsalis, or general paresis, without mental im- 
pairment. In rare cases there is a compression myelitis. Paraly- 
sis agitans, Charcot's claudication and senile tremor are sup- 
posed to be due to spinal degeneration following arteriosclerosis 
of the vertebral vessels, but these conditions are sometimes 
found in cases in which no spinal or arterial degeneration could be 
discovered. In Charcot's claudication there is an intermittent 
lameness following prolonged walking. The limb feels cold, 
there is rapid numbness, pain and sudden inability to move the 
limb. This passes off after rest but will return upon exercise of 
the limb. In this form of claudication the step is normal, but 
in other forms the step may be unsteady, short and tripping or 
slow, cautious, and long, dragging or jerking. 

Peripheral Arteriosclerosis. — In peripheral arteriosclerosis the 
anatomical and functional changes occur in the muscles and skin. 
There is a sallowness resembling the cancer cachexia, local symp- 
toms of numbness, coldness, tingling and other paresthesias, 
cramps, myalgia, pruritus, purpuric eruptions and other forms 
of skin disease. Senile gangrene is often due to localized arterio- 
sclerosis and Raynaud's disease, when occurring in the aged, is 
supposed to be due to peripheral arteriosclerosis and neuritis. 
Many cases of senile gangrene give a history of local syncope and 
asphyxia preceding the gangrene and are really cases of Ray- 
naud's disease in which the earlier symptoms were neglected. 

Diagnosis. — The protean character of arteriosclerosis and the 
impossibility of differentiating between similar visceral symptoms 



88 PATHOLOGICAL OLD AGE 

due to this and to other causes make diagnosis difficult and 
errors frequent. After the hardening of the radial artery has 
become so pronounced as to be recognized by the finger, the diag- 
nosis is evident, but by this time the disease has advanced so far 
that nothing, or but very little can be done to improve the con- 
dition. An early diagnosis is of the greatest im.portance and in 
the absence of pathognomonic symptoms we must consider etio- 
logy, pathology, and general symptoms and we may be obliged 
to depend upon the result of treatment to prove the correctness 
of our diagnosis. 

In senile arteriosclerosis the principal etiological factor is 
age. Then come occupation and mode of life, mental labor 
favoring cerebral arteriosclerosis, exciting or difficult physical 
labor predisposing to central arteriosclerosis, etc. 

Early physical signs are cardiac hypertrophy, accentuation 
of the second sound of the heart and high blood pressure. In 
precocious senility, we have an unfailing sign in early ossification 
of the costal and xiphoid cartilages. The earliest symptoms will 
depend upon the location of the disease. If in the head, headache 
upon arising and occasional vertigo will be noticed. In the arms 
or legs there may be muscle cramps after exercise. In making 
our diagnosis of arteriosclerosis of an abdominal viscus we must 
be guided by the symptoms and signs of generalized arterio- 
sclerosis. In the absence of such symptoms and signs if the 
ordinary treatment for the local conditions is ineffectual a single 
dose of nitrite of soda or nitroglycerin may clear up the diagnosis 
by giving immediate relief. This is of especial service in the 
diagnosis of cases involving spinal symptoms. Many of the 
symptoms given above may be due to antecedent disease to which 
the arteriosclerosis is secondary and it is not unusual to have the 
cause for secondary arteriosclerosis prevail in old age. It is thus 
possible to have a primary senile degeneration and a secondary 
degeneration of the arteries following syphilis, gout, and infec- 
tious disease, etc., prevail at the same time, either affecting dif- 
ferent organs or one aggravating the other. 

Prognosis. — The prognosis of senile arteriosclerosis is un- 
favorable. It is progressive and generally destroys the indi- 
vidual either through exhaustion of the heart or through im- 
pairment of some other organ to such extent as to prevent its 
functions or through cerebral compression following cerebral 




Arteriosclrosis of Posterior Tibial 



Artery. (Courtesy of Lewis Gregory Cole, M. D., 
Xew York.) 




Arteriosclerosis of Peroneal Artery. (Courtesy of Lewis Gregory Cole, M. D., 

New York.) 



SENILE ARTERIOSCLEROSIS 89 

hemorrhage. Occasionally an embolus blocks a vessel and 
prevents the nutrition of a part causing its rapid degeneration, or 
in the case of the lungs causing fatal dyspnea. In the case of 
embolism, death may also be due to shock. General exhaustion 
due to profound changes in the organs and nerves controlling 
metabolism can generally be traced to arteriosclerosis. 

The progress is normally slow but is hastened by improper 
living, poor quality of food, lack of exercise and vitiated air. 
Cardiac hypertrophy^ keeps pace with the impairment of the 
circulation due to degeneration of the vessels. With the limit 
of hypertrophy is also reached the limit of tonicity. Further 
strain results in broken compensation and dilatation and this 
ends in cardiac exhaustion. 

In the secondary arteriosclerosis, the prognosis will depend 
upon the cure of the primary disease and the activity of the 
metabolic processes. In young individuals in whom the ana- 
bolic processes surpass the destructive forces, the inhibition of 
the cause and elimination of waste will prevent further degenera- 
tion and remove the pathological tissue which will be replaced 
by new tissue. In senile cases the metabolic processes proceed 
slowly, and as the repair is accomplished through the blood 
which is deficient in quality and quantity, a lower type of tissue 
is formed to replace the degenerate tissue. In this way the 
character of the tissue is altered through the proliferation of 
connective tissue and waste of normal substance. 

Treatment. — Senile arteriosclerosis being a natural, normal 
condition is incurable in the sense that it can neither be pre- 
vented nor removed. The best that we can hope for is to retard 
its progress and relieve disagreeable symptoms. 

Before beginning treatment we must be certain that the con- 
dition is not a secondary disease. If the patient has ever had 
syphilis, acute articular rheumatism or gout, though the symp- 
toms had disappeared years before, drug treatment applicable 
to the primary disease should be instituted. In these cases the 
iodides are serviceable. It does not matter in what form the 
iodine is introduced whether in the form of inorganic salts or 
organic preparations the effect upon the blood-vessels and the 
blood is the same. The objection to the iodide of potas- 
sium is its irritating effect upon the gastric mucous mem- 
brane. This is not as pronounced if the iodide of sodium is 



90 PATHOLOGICAL OLD AGE 

used. The iodide of arsenic in i/i 5-grain doses is the most valu- 
able of all the inorganic iodine compounds, the arsenic being 
a tonic and an anabolic stimulant. It is, however, eliminated 
slowly and produces cumulative toxic effects. If it is employed, 
it must be discontinued as soon as the physiological effects of 
arsenic — gastric irritation, metallic taste or swelling under the 
eyelids — appear. Some of the organic iodine preparations do 
not affect the stomach, nor do they produce rashes, nasal or 
bronchial catarrh or other untoward effects. The extravagant 
claims made by the manufacturers of these organic compounds 
deter the author from recommending any one in particular. 
The iodides should never be used if there is high blood pressure 
and low viscosity of the blood as the iodides still further 
lower the viscosity thereby favoring hemorrhage, especially 
miliary hemorrhages from the cerebral vessels. Lime salts 
are positively contraindicated there being already an excessive 
retention and diminished elimination of calcium. In senile 
arteriosclerosis no drug will permanently improve the condition 
of the arteries. Whatever permanent benefit can be brought 
about must come from the regulation of the mode of life of 
the individual. Drugs must however be employed to relieve 
the disagreeable concomitants of arteriosclerosis either by 
lowering the blood pressure or by local treatment of the part 
giving the disagreeable symptoms. 

Many drugs will lower blood pressure yet some in doing so 
produce direct or secondary effects more serious than the condi- 
tion they are intended to relieve. Aconite, gelsemium and 
veratrum viride lower blood pressure by depressing the heart, 
weakening its force and slowing its action thereby diminishing 
the blood supply to organs and tissues already impaired through 
insufficient nutrition. These drugs should be used only when 
there is a rapid and full pulse not due to nervous causes and then 
they should be combined with a cardiac stimulant which has 
no vasoconstrictor effect. 

The choice of drug to diminish the blood pressure must 
depend upon its action upon the heart, the vessels and the blood. 

The favorable action of the iodides is due to the property of 
reducing the viscosity of the blood, thereby allowing the blood 
to flow more freely through the contracted vessels. It has been 
suggested that they stimulate metabolic activity either by direct 



SENILE ARTERIOSCLEROSIS 91 

action upon degenerate tissue or by stimulation of the thyroid 
gland. They are useless when the degeneration is part of the 
normal process of involution and even small doses will produce 
the physiological effects, iodism with rashes, catarrhs and local 
irritation. The calcium compounds of iodine have the addi- 
tional disadvantage of increasing the viscosity of the blood and 
furnishing an excess of calcium. 

The most valuable drugs to reduce blood pressure are the 
nitrites which act by dilating the arterioles. In angina pectoris 
where rapid action is required amiyl nitrite used by inhalation 
produces an almost instantaneous effect, lasting, however, but 
a few minutes. Nitroglycerin in doses of one or two minims of 
a I per cent, solution acts almost as rapidly when given hypoder- 
mically and somewhat slower when given by mouth. The action 
lasts about fifteen minutes. The nitrite of soda in grain doses 
acts in fifteen to twenty minutes and its action lasts two or three 
hours. Erythrol tetranitrate has been recommended on account 
of its more prolonged action, but it possesses no other advantage. 
It is given in |-grain doses. The dose of the nitrites depends to 
a great extent upon the tolerance or idiosyncrasy of the patient 
and the condition of the cerebral vessels. If there is cerebral 
hyperemia a sudden influx of blood may cause rupture of a 
vessel. The long-continued use of the nitrites may cause per- 
ipheral stasis while the drugs themselves act as blood toxins. 
Thyroid extract controls high blood pressure and has been highly 
extolled in the treatment of arteriosclerosis. In the author's 
experience small doses produced distressing palpitation of the 
heart and the blood pressure rose within a day after its use 
was discontinued. 

Theobromin and its combinations have been employed to 
reduce blood pressure. Huchard recommends its use as it 
dilates the peripheral vessels and stimulates the heart and the 
kidneys. Diuretics lower blood pressure through the abstrac- 
tion of fluid from the circulation. This, however, is a dis- 
advantage since it increases the viscosity of the blood and the 
system demands restitution in thirst which cannot be ap- 
peased until sufficient fluid has been imbibed to supply the 
deficiency. 

Electrotherapeutists report reduction of blood pressure 
through high-voltage currents, but this method of treatment is 



92 PATHOLOGICAL OLD AGE 

experimental and there are divergent views as to the utility of 
electricity in this condition. 

Among general measures employed in arteriosclerosis, Trune- 
cek's serum deserves attention. This is a solution of the var- 
ious salts in the proportion in which they are found in the plasma. 
The theory of its employment is based upon Weil's theory of 
disproportion of salts in the blood, Trunecek arguing that by 
administering the plasma salts the plasma would finally hold 
the normal proportion, any excess of one or more salts being 
eliminated by the kidneys. It is believed that decalcification 
of the vessels cannot be accomplished by chemical means, 
and consequently such result, if accomplished at all, must be 
brought about through altered metabolism. This is the only 
explanation that can be given for the favorable results ob- 
tained in many arteriosclerotic cases treated by the Trunecek 
serum or salts. (The salts are marketed under a trade 
name.) 

In treating local conditions the effect of drugs rarely lasts 
longer than the period of effectiveness of the last dose. If 
there is pain morphine will relieve it but if the cause persists 
the pain will return. For insomnia 5 to lo grains of veronal 
may be given at bed time but care should be taken that the blad- 
der is emptied. A hot foot bath in the morning will relieve the 
morning headache and a whiff of ammonia or thirty minims of 
the aromatic spirits of ammonia can be used for the vertigo. 
The attacks of vertigo usually last but a moment and pass 
away before treatment can be instituted. Muscle cramps in 
the limbs will disappear if hot water or hot cloths are applied 
and the same treatment will generally relieve claudication. 
(Treatment of other local conditions will be given under the 
description of such conditions.) Hygienic and dietetic measures 
take first place in the treatment of arteriosclerosis as the dis- 
regard of such measures is mainly responsible for this disease or 
its early appearance. 

The most important rule is the diminution of food to the 
amount actually required to maintain strength, the elimination 
as far as possible of purin-forming protein foods, a minimum of 
lime-containing foods and of those containing much cellulose 
and other indigestible material. The amounts should not be left 
to the judgment of the individual but it should be regulated as 



SENILE ARTERIOSCLEROSIS 93 

carefully as in the treatment of diabetes. The amount of tea 
and coffee should be cut down but they need not be entirely 
eliminated. Alcohol is injurious yet the sudden and total depri- 
vation of alcohol to a person accustomed to it will produce 
mental depression. It should be cut down gradually. Beer 
is worse than spirituous liquors while light dry wines are the 
least objectionable. 

The loss of the teeth in old age is a physiological indication 
that foods requiring thorough mastication are unsuitable and 
this applies especially to meat. If there is evidence of intes- 
tinal decomposition in foul-smelling stools, intestinal antisep- 
tics are required. For temporary use we can employ salol, 
salicylic acid or the sulpho-carbolates. For prolonged use the 
lactic acid ferments are best. When the disease is far advanced 
and there is broken compensation and renal difficulties milk 
must form the principal article of diet. Non-alcoholic malt 
extract is a valuable adjunct to the food of the aged. 

It is hardly necessary to insist upon a daily evacuation of 
the bowels. 

Many writers dilate upon the injiirious effects of smoking 
yet most old men are smokers. Excessive smoking as well as 
excesses in other things is injurious but it need not be forbidden 
entirely unless headache or vertigo follows. 

Excessive physical exercise should be forbidden and it should 
be an imperative rule for the patient to rest as soon as he begins 
to feel fatigued. Further exertion can be carried on only under 
a forced impulse which strains the heart, increases the circulation 
abnormally and hastens degeneration of the vessels and organs 
involved. A sudden exertion or intense excitement is liable to 
cause paralysis of the heart. Mild mental and physical labor 
is beneficial before myocardial incapacity has set in, but after- 
ward complete mental and physical rest is necessary. In the 
early stage active elimination of toxic material by catharsis, 
diiu-esis and diaphoresis is advisable. Later on the eliminative 
treatment should be continued but not forced unless local con- 
ditions such as constipation or enuresis make it necessary. 
Extreme changes in temperature, in climate, in air pressure 
as when going from the seashore to the mountains, should be 
avoided. A cheerful spirit, keeping the mind pleasantly 
employed and free from worry, and the kindly ministration of 



94 PATHOLOGICAL OLD AGE 

the family and the physician often do more to reHeve the dis- 
agreeable symptoms than drugs or other measures. 

Amorphous Phosphorus in Senile Arteriosclerosis. — The 

author has used the red amorphous phosphorus in senile arterio- 
sclerosis for several years. Given originally as a substitute for 
ordinary phosphorus in senile debility it was found that it was 
eliminated as amorphous phosphate of lime and that the lime 
elimination was thereby increased. Weil's experiments showed 
that the lime elimination in arteriosclerosis was diminished. 
Phosphorus has the property of combining with lime and increas- 
ing the lime assimilation. In the small doses which can be given 
when the ordinary phosphorus is employed the phosphorus 
will combine with the lime of the food and increase the amount 
of lime salts in the body. When given as amorphous phos- 
phorus the dose is two grains or more several times a day, and 
with a lime-free diet the lime required for the combination 
necessary to secure the elimination of the phosphorus excess, is 
drawn from the abnormal lime deposits. This appears to be the 
rationale of the treatment and explains the good results obtained 
from its use. 



SENILE PHLEBOSCLEROSIS 

Phlebosclerosis is a degeneration of the walls of the veins 
analogous to the degeneration of the arterial walls. 

Etiology. — A primary senile degeneration of the veins is 
rare and occurs almost exclusively in veins subjected to great 
pressure such as the veins of the lower extremities. The dis- 
ease generally follows a phlebitis, a pyemia or an infectious dis- 
ease and may then occur at the site of the phlebitis, or elsewhere. 
If there is no antecedent disease, the degeneration is due to 
impaired nutrition through contracted vasa vasorum as occurs 
in arteriosclerosis. 

Pathology. — Primary degeneration through impaired nutri- 
tion presents similar histological changes as are found in arterio- 
sclerosis. The elastic and muscular fibers waste and permit 
dilatation of the vesesl and the production of varicose veins. 
This causes slowing of the current with production of thrombi 
in the pouches of the varicosed portions of the vessels. 



SENILE DEGENERATION OF THE HEART 95 

Symptoms. — Phlebosderosis presents no marked symptoms. 
Sometimes areas of hardness can be felt along the course of 
superficial vessels, ordinarily, however, the symptoms are those 
of varix. If lumps are felt in the varix dilations they are usually 
due to thrombi. A thrombus in a vessel which is not dilated, 
interferes with the circulation and causes local edema, becoming 
worse and accompanied by pain upon prolonged standing. A 
hypostatic edema of the ankles and feet, frequently met with in 
the aged, is probably due to phlebosderosis. This edema is 
slight except after prolonged standing or walking. The physical 
fatigue produced by such exercise necessitates rest and thus 
any great accumulation of plasma in the subcutaneous tissue, and 
the discomfort which would accompany extensive exudation, is 
avoided. 

In making a differential diagnosis of phlebosderosis from 
this form of edema w^e must eliminate cardiac and renal disease, 
anemia, flatfoot and obesity. It may occur in varicose veins. 

Treatment. — There is no treatment for phlebosderosis. 
The treatment for venous thrombus and varicose veins is given 
under varicose veins. For the edema rest and rubber ankle 
supporters will give relief, but the condition progresses with 
the cause. 

SENILE DEGENERATION OF THE HEART 

The earliest cardiac change due to age is cardiac hypertro- 
phy. This is not a senile change but the ordinary trophic in- 
crease in muscular development that occurs normally in all 
striped muscles actively employed. The hypertrophy caused by 
the greater effort of the heart to send the blood through vessels 
having diminished contractile power or diminished caliber, 
does not differ from the hypertrophy due to excessive exercise 
in earlier life. The athlete's hypertrophied heart remains 
enlarged for years after the athletic work has been given up and 
may become a permanent condition. The hypertrophy of 
the senile heart is confined to the left ventricle until the valves 
are involved. 

There is a limit to muscular capacity and when this has been 
reached further activity will cause muscle exhaustion or degen- 
eration. The muscle can recover from exhaustion upon com- 



96 PATHOLOGICAL OLD AGE 

plete rest but as the heart cannot absolutely rest, degeneration 
takes place. The usual degenerative change in these cases is a 
loss of tonicity of the muscle fiber whereby its irritability and 
contractility are diminished and it stretches, permitting a dila- 
tation of the cavity. While dilatation of the heart is the most 
frequent sequel of cardiac disorders peculiar to the aged, it is 
not a senile degeneration and will therefore be discussed in the 
fourth group. The senile myocardial degenerations are myofi- 
brosis and brown atrophy, the former occurring most frequently 
when the hypertrophied heart has been reached the limit of its 
functional capacity and further strain causes exhaustion, 
atonicity and degeneration. Brown atrophy occurs most fre- 
quently in hearts that have not been greatly hypertrophied, 
but in which coronary arteriosclerosis appeared early and inter- 
fered with the nutrition of the organ. Myofibrosis is therefore a 
mechanical degeneration, while brown atrophy is a nutritional 
degeneration. Other degenerations, though frequent in the 
aged, are not strictly senile processes. 

Senile Myofibrosis 

Senile myofibrosis, erroneously called chronic myocarditis, is 
a degeneration of the cardiac muscle marked by an increase of 
the interstitial connective tissue with waste of muscle fiber. It 
corresponds to the nutritional type of arteriosclerosis. It is the 
usual form of senile degeneration and in its milder form is normal. 

Etiology. — Myofibrosis is due to impaired nutrition either 
from some fault in the blood or from diminished supply through 
coronary sclerosis. 

As myofibrosis is one of the terminal results of malnutri- 
tion whether due to impaired quality of the blood or to diminished 
quantity, anything which will cause either of these may produce 
a myocarditis and consequent degeneration. The diminished 
blood supply causes insufficient repair of muscle waste, but 
there is sufficient to supply hyperplastic connective tissue which 
requires less nutrition or perhaps the blood of the aged contains 
more of the nutritional elements required by the connective 
tissue and less of the elements required to repair muscle w^aste. 
This would explain the general tendency to fibrosis in old 
age. 




Myofibrosis (Chronic ^Myocarditis). (Schmaus.) X 150 
diameters, m. Cardiac muscle-fibers, b, b. Newly formed 
fibrous connective tissue. This can often be demonstrated 
to be of different ages, and in the older parts calcareous 
change may have occurred. 



SENILE MYOFIBROSIS 97 

Satterthwaite has shown how an embolus from chronic 
endocarditis might be arrested in a branch of the coronary 
artery and produce local infarct with fibrosis. Chronic endo- 
carditis may follow an acute myocarditis, endocarditis, pericardi- 
tis, infectious disease, syphilis, gout, nephritis, diabetes, or 
alcohol, lead, or tobacco intoxication. 

Pathology. — Senile myofibrosis affects the whole organ 
but the hyperplasia is most marked in the auricles. In the early 
stage of the disease the heart is usually enlarged, hypertrophied 
or dilated, later as the muscle waste proceeds it becomes smaller. 
There is an increase of connective tissue and a waste of muscle 
fiber, but the muscle fibers are not infiltrated with granular 
matter as occurs in myocarditis following infectious diseases 
and toxins. They may present segmentation and fragmenta- 
tion. The heart feels harder and when cut across it looks lighter 
in color than normal. The valves are usually affected but this 
may be due to a senile endocarditis or to other senile changes. 
In some cases there is in addition to the fibrosis a fatty degenera- 
tion of some fibers. It is not known what particular factor 
determines the character of the degeneration, fatty or fibrous, 
when the blood supply is diminished. As there is in both the 
same underlying etiological factor — insufficient blood supply — 
the determining factor must be sought for in the blood itself. 
Dilatation is a frequent sequel. 

Symptoms. — Senile myofibrosis produces progressive heart 
weakness. The force of the contractions is diminished and 
slight causes will produce arrhythmia and palpitation, while 
intense excitement may produce delirium cordis, spasm or heart 
block. In the mild form there may be no symptoms except 
perhaps palpitation, vague precordial distress and dyspnea upon 
slight exertion, but these symptoms may be so mild as to pass 
unnoticed. When the disease is further advanced there is 
usually a weak irregular pulse and weak apex beat, the symptoms 
of imperfect aeration, dyspnea and cyanosis with headache 
and the symptoms of cerebral anemia, facial pallor, blanched 
conjunctivas, and a feeling of emptiness in the back of the head 
with occasional vertigo, and the symptoms of surface anemia, 
pale, cold, dry skin. Irritability of temper is frequent. Other 
organs become affected through impaired circulation, insufficient 
blood supply and passive congestion. Neurasthenia occurs 
7 



98 PATHOLOGICAL OLD AGE 

frequently and angina pectoris occasionally, due to coronary 
sclerosis, i 

Diagnosis. — While the various forms of cardiac degeneration 
present differences in their pathology, it is often impossible to 
distinguish between them clinically. In many cases the history 
will determine the diagnosis. Any cause which will produce 
an acute myocarditis will produce a chronic myocarditis with 
consequent fibrosis. The acute myocarditis is, however, very 
rare in the aged and is almost always a secondary infection 
or intoxication most frequently following an influenza. The 
chronic myocarditis is secondary to acute myocarditis from 
toxin or gout, rheumatism, etc. In senile myofibrosis the ante- 
cedent relations are cardiac hypertrophy and coronary arterio- 
sclerosis, the former causing degeneration through overac- 
tivity and consequent exhaustion, the latter through malnu- 
trition. The symptoms of acute myocarditis are pain and a 
feeling of oppression over the heart, anxiety and a fear of death, 
feeble and irregular heart action, the pulse small, irregular 
and gradually weakening. In chronic myocarditis the symp- 
toms of the acute form appear milder and more persistent, 
there is dyspnea and later cyanosis. It is often difficult to 
differentiate between chronic myocarditis and senile myofibrosis 
except by the history and by the course of the disease. Senile 
myofibrosis is progressive and while its progress may be retarded 
it cannot be halted while myocarditis may be cured. In both 
diseases the symptoms improve after prolonged rest but in 
senile fibrosis the heart becomes weak again after exercise. 

Fatty degeneration produces similar symptoms but the 
heart is persistently weak while in fibrosis the heart is sometimes 
fairly strong, especially after prolonged rest. In brown atrophy 
the size of the heart is diminished and symptoms of coronary 
arteriosclerosis are frequent while in myofibrosis there is usually 
enlargement of the heart and coronary symptoms are infrequent. 

Treatment. — The treatment of senile myofibrosis must be 
hygienic and symptomatic. The condition is slowly progressive 
and we can do nothing to arrest its progress nor to restore 
degenerate tissue. The symptoms are usually so mild that 
they are neglected by the patient and are but mentioned inci- 
dentally when complaining of the more distressing symptoms 
of some other disease. (The treatment of the incidental symp- 




Bramwell's "withered apple'' heart. (Satterthwaite, 
Med. Record, ]\Iay 14, 1910.) 



BROWN ATROPHY OF THE HEART 99 

toms arrhythmia, palpitation and angina pectoris will be given 
under Cardiac Neuroses.) 

When cardiac weakness becomes marked the most important 
measure is rest. Digitalis is contraindicated as the degenerated 
fibers cannot respond and the excessive work imposed upon the 
healthy fibers causes their rapid degeneration while its vasocon- 
strictor action further diminishes the blood supply to the 
heart by contracting the coronaries. Where there are marked 
symptoms of cerebral and peripheral anemia the nitrite of soda 
in i/6-grain to i -grain doses four times a day should be given. 
Alcohol in the form of whiskey or wine given with meals is 
often beneficial. Late in the disease camphor, caffein, strychnin 
and strophanthin may become necessary. In regulating the 
life of the patient the avoidance of sudden strain is of the greatest 
importance. Even straining at stool is injurious and may 
cause sudden cardiac exhaustion. A profound emotion may 
do the same. Some exercise is necessary but it must not pro- 
duce fatigue or strain and it must be stopped as soon as dyspnea 
or palpitation appear. The rarified air of the highlands is 
detrimental. The Schott, Nauheim and Oertel treatment are 
dangerous and should not be used in senile cases notwithstand- 
ing favorable reports from those interested in institutions giving 
such treatments. 

Dietary restrictions are directed principally to non-constipat- 
ing foods. Sexual excitement should be avoided. (The treat- 
ment for coronary arteriosclerosis is given under Arteriosclerosis.) 

Brown Atrophy of the Heart 

Brown atrophy is an infrequent physiological, atrophic 
condition of the senile heart. It must be observed that degenera- 
tion of the heart muscle occurs normally much later than the 
degeneration in other organs and tissues and upon autopsy of 
aged individuals we frequently find no cardiac change other 
than hypertrophy or dilatation with the accompanying valvular 
lesions and perhaps a senile endocarditis. 

Etiology. — It occurs normally if there is a slowly develop- 
ing coronary arteriosclerosis without marked hypertrophy. It 
has been found also in younger individuals who were suffering from 
prolonged toxemias, tachycardia and overwork. 



lOO PATHOLOGICAL OLD AGE 

Pathology. — In brown atrophy the heart is diminished in 
size and there is little or no hyperplasia of connective tissue. 
The muscle cells are atrophied and there is a deposit of brownish 
pigment about the nuclei. The muscle striations become 
obscure but segmentation and fragmentation does not occur. 
The heart is of a dark brown color and may appear shrunken 
and withered with the vessels brought out in relief. 

Symptoms. — The symptoms are those of cardiac weakness. 
There is a weak apex beat and weak pulse becoming irregular in 
rhythm and force upon exertion or excitement. At such times 
there are also dyspnea and palpitation and the patient becomes 
irritable. In advanced cases there are the symptoms of imper- 
fect aeration, cerebral and peripheral anemia, and functional im- 
pairment of other organs and tissues through impaired circula- 
tion and passive congestion. The symptoms are the same as in 
other forms of myocardial degeneration and the diagnosis will 
depend upon the diminished area of cardiac dulness, the age 
and the exclusion of other causes of cardiac atrophy, starvation 
and wasting diseases. The atrophic stage of senile fibrosis oc- 
curs late, perhaps years after the earlier symptoms called atten- 
tion to this condition. 

Treatment. — What has been said of treatment under senile 
fibrosis applies to brown atrophy. Hygienic measures, especially 
the avoidance of physical exertion, strong emotions and excite- 
ment are more important than drugs. 

SENILE ENDOCARDITIS 

This form of chronic endocarditis is a senile degeneration of 
the endocardium and is usually part of a general arteriosclerosis. 
It cannot be differentiated except etiologically from the chronic 
endocarditis that follows the acute form and from the sclerotic 
endocarditis that is induced by alcohol, syphilis, autogenous 
toxins, excessive exercise, etc. 

Etiology. — When part of a general arteriosclerosis, there 
are the same etiological factors (see senile arteriosclerosis). In 
rare cases there is an extension of the sclerotic process from the 
aorta to the aortic valve and to the left ventricle. 

Pathology. — The changes in the endocardium are like the 
degenerative changes in the endothelial layer of the blood-vessels. 




W^^' 



Pulmonary fibrosis, usually described as Chronic Interstitial 
Pneumonia, a condition frequently found in senile lungs. Illustration 
from Coplin's "Manual of Pathology." 

Bands of fibrous tissue following course of interlobular septa and 
surrounding blood-vessels and bronchi. {Landis, Fifth Ann. Rep. of 
Phipps Inst.) 



SENILE DEGENERATION OF THE LUNGS lOI 

The membrane becomes thickened and firmer, there is frequently 
a covering layer of fibrin over atheromatous patches and occasion- 
ally calcareous plates are found. The changes are most pro- 
nounced about the valves which become thickened and misshapen 
and lose their elasticity. The cordae-tendinae become sclerosed. 
The aortic valve is most frequently involved, the structural 
changes producing insufficiency. 

Symptoms. — This condition cannot be diagnosed until the 
valves are involved, when the symptoms of valvular disease 
appear. There may be occasional precordial distress , arrhythmia, 
palpitation, etc., but nothing distinctive upon which to base a 
diagnosis. 

Treatment. — The treatment depends upon the valvular 
disease that is produced. 



SENILE DEGENERATION OF THE LUNGS 

Senile atrophy of the lung is a physiological condition, 
but it may produce so much distress as to require medical 
intervention. 

Etiology. — A number of causes combine to bring about pul- 
monary degeneration. Apart from theoretical causes, tissue- 
cell evolution and a change in the character of the blood, arterio- 
sclerosis of the pulmonary vessels diminishes the quantity of 
blood sent through the lungs. Pneumokoniosis stimulates 
connective-tissue hyperplasia and the contraction of this fibrous 
tissue compresses the lung tissue. The lungs are further com- 
pressed by the rigidity of the chest walls. There is then in- 
sufficient nutrition and mechanical compression, causing waste 
of tissue. 

Pathology. — The lung undergoing senile degeneration is 
smaller than in maturity, discolored, and on section presents 
minute cavities. These are due to the waste of the alveolar septa 
whereby the air cells coalesce and the condition called small 
chest or senile emphysema is produced. The residual air is in- 
creased, the vital capacity is diminished and both inspiration 
and expiration are lessened. 

Symptoms. — The symptoms of senile degeneration of the 
lungs become distressing when there is marked emphysema. 



I02 PATHOLOGICAL OLD AGE 

The diminished respiration and lessened aerating surface cause 
incomplete aeration of blood and consequent cyanosis but this 
produces very little or no distress. The real distressing symp- 
tom of pulmonary degeneration, ''dyspnea," is due to senile 
emphysema. 

Senile emphysema differs from the emphysema of maturity 
in the absence of the barrel-shaped chest which is almost pathog- 
nomonic of this disease in earlier life. In the senile form the chest 
walls are rigid, there is no respiratory expansion and the respira- 
tion is carried on mainly by the diaphragm. When the dyspnea 
is severe, there is a raising and dropping of the entire thorax, 
the supra- and infraclavicular spaces sink and the muscles of the 
neck are prominent. Percussion shows that the lungs lie lower 
than in maturity, the apex is lower and the percussion here is 
indistinct. The percussion note in senile emphysema is peculiar, 
there being a typanitic resonance without the momentary 
echo sound that accompanies the hyperresonance of ordinary 
emphysema. Upon auscultation we get a weak vesicular mur- 
mur with prolonged expiratory note. If the patient has been 
lying upon his back, immediately upon arising dry crepitant 
r^les can be heard at the lower part of the back during the first 
few inspirations. This is due to the opening of the air vesicles 
in that part of the lungs, which were compressed in the recum- 
bent position and is a pathognomonic sign of this condition. 

Moist rales are due to bronchitis. The latter if present is 
not associated with senile emphysema as in other forms of em- 
physema, but is an accidental complication. The dyspnea of 
senile emphysema is both inspiratory and expiratory, the latter 
more pronounced. In the early stage it appears only upon ex- 
cessive exertion, later slight exertion as walking up a few steps, 
may bring it on. When this occurs there is extensive involve- 
ment of the lungs, with cyanosis and cardiac disease. Usually 
senile emphysema gives no symptoms until the disease is far 
advanced, as the physical condition of the individual prevents 
him from undertaking difficult tasks which might cause dyspnea. 

Treatment. — Prophylactic measures can be employed to defer 
the atrophy of the lungs. A cane should be used as soon as it 
is noticed that the ageing individual walks with a stoop. Shoul- 
der braces are useful but irksome. Deep breathing, taking a 
long, steady deep breath should be practiced several times a day. 




Section of the Lung, Pneumoconiosis. (Rindfleisch.) The deposited pic 
ment is shown in the connective tissue of the vesicular wall. 



r 




Dilated stomach. Combined dis- 
placement and dilatation of lesser de- 
gree. (From Greene after Riegel.) 



PNEUMOKONIOSIS IO3 

When seated, the person should use an arm chair and keep his 
arms upon the rests. A warm, dry, equable climate at low ele- 
vation and free from dust is the most important hygienic meas- 
ure. Mild exercise is beneficial but fatigue must be avoided. 
The individual should change his position frequently, alternating 
between walking, standing, sitting and lying down. Bella- 
donna is useful as a stimulant to the respiratory centers and 
oxygen inhalation for cyanosis. 



PNEUMOKONIOSIS 

Pneumokoniosis or fibrous induration of the lung is caused 
by the constant inhalation of dust. 

Etiology. — Dust is inhaled in the air stream from birth. 
Most of the dust is caught by the ciliated epithelium of the 
bronchi, but some reaches the alveoli and works its way or is 
possibly carried by phagocytes into the lymph spaces and con- 
nective tissue, causing a chronic irritation with consequent 
hyperplasia of such tissue. Some induration from this cause is 
found in every aged individual. It is more pronounced among 
city dwellers, especially in manufacturing towns in which there 
is much soot and dust in the atmosphere, and occurs to but a 
slight extent in sailors of sailing vessels. 

Pathology. — The lungs are discolored, the pigment ranging 
from gray to black, depending upon the character and quantity 
of dust that had been inhaled. This discoloration may be uni- 
form throughout the lungs or appear in scattered areas giving 
the lung a mottled appearance. There is a hyperplasia of con- 
nective tissue, the new tissue being pigmented. Dust particles 
may be found in the alveolar epithelium. As hyperplasia of 
connective tissue occurs normally in the process of involution, 
it is probable that the fibrous induration generally found in senile 
lungs is part of this normal degeneration, while the slow accumu- 
lation of dust, acting as an irritant, plays but a small part in the 
proliferation of the connective tissue. Senile pneumokoniosis is 
almost invariably associated with atrophic emphysema, the two 
producing the typical atrophied lung of senility. 

Symptoms. — The slow progressive pneumokoniosis of old age, 
which has not been aggravated by vocational dust inhalation, 



I04 PATHOLOGICAL OLD AGE 

gives no marked symptoms, except perhaps a hypertrophic 
bronchitis. The emphysematous symptoms which occasionally 
accompany it are due to the senile emphysema. The sputum is 
gray, tenacious and thick, containing leucocytes and cells from 
the bronchial and alveolar mem.branes with enclosed dust 
particles. Those suffering from the vocational forms of pneu- 
mokoniosis, like miners, knife grinders, glass and metal en- 
gravers, sand-blast operators, stone cutters, etc., rarely reach old 
age, as the dust particles which they inhale are sharp, cut into 
the tissues, cause necrosis and produce cavities. 

Pneumokoniosis is sometimes called primary chronic in- 
terstitial pneumonia. The latter disease is generally localized 
and unilateral, and there is no discoloration of tissue. Septic 
infection frequently occurs and results in gangrene. 

Treatment. — Pneumokoniosis is incurable. If there are dis- 
tressing symptoms, such as dyspnea or excessive expectoration, 
the treatment must be directed to the emphysema or bronchitis 
which causes the symptoms. The patient should be removed 
from the smoky or dust-laden atmosphere, preferably to the 
seashore. If an aged person suffering from bronchitis moves 
from the clear atmosphere of the country, to a smoky city, dis- 
tressing symptoms rapidly follow. 



SENILE DEGENERATION OF THE ORAL CAVITY 

The degenerative changes in the mouth and pharynx are not 
marked except by the loss of the teeth, yet this has a marked 
influence upon the health and welfare of the individual. 

The teeth crack and break, their nerves and blood-vessels 
atrophy and with the atrophy of the alveolar process the teeth 
become loose and fall out. The mucous coating of the mouth 
becomes thin and pale, the glands atrophy, and likewise the 
salivary glands. The secretions are diminished but not altered. 
The change in the shape of the inferior maxilla is the most marked 
osseous senile change in the body. The muscles of mastication 
and deglutition waste and lose their tonicity. Owing to the loss 
of the teeth and the waste of muscles a decided effort must be 
made to approximate the gums and for this reason the jaws are 
never brought together except by a special effort of the will 



SENILE DEGENERATION OF THE ORAL CAVITY 105 

although the lips may be closed easily. In some cases the 
openings of the saHvary ducts are dilated permitting a dribbling 
of saHva into the mouth and if the lips are flaccid and not 
tightly closed the sahva drips out. As a result of these changes 
and of evident changes in the nerves and taste bulbs which 
have, however, never been demonstrated, profound changes 
occur in mastication and deglutition, in the appetite and in 
buccal digestion. 

The loss of the teeth prevents mastication and necessitates 
a change in diet, the most important dietary change being the 
elimination of meat. While the loss of teeth can be repaired 
artificially, making the elimination of meat apparently un- 
necessary, this loss in the healthy aged person seems to keep 
pace with the senile degeneration of the stomach. Owing to 
degeneration of that organ meat digestion becomes more diffi- 
cult and it would seem that the loss of teeth is really a natural 
provision to prevent excessive work for the senile stomach. 
Diminished appetite has probably the same purpose, lessening 
the amount of the ingesta in proportion to the needs of the sys- 
tem and to the diminished activity of the excretory organs. 
Senile dysphagia is part of the same natural provision to prevent 
overfeeding. The individual must make a sensible effort to 
swallow. SoHds pass more readily than liquids; acid, sour, 
sharp, and acrid substances are swallowed more easily than 
alkaline, sweet and insipid substances. Lessened thirst is prob- 
ably due to a dulling of the sensibiHties of the nerve terminals 
and, Hke diminished appetite, is a compensatory arrangement 
to give less work to the heart and kidneys. 

Nothing can be done for the dysphagia and nothing need be 
done for the other conditions except for the drivel of saliva. 
It is sometimes possible to instil a sense of neatness in the indi- 
vidual so that he will make an effort to control it. If this fails 
it may be possible to control it by local astringent applications 
to the mouths of the ducts. There is, however, danger of pro- 
ducing stenosis with complete drying and atrophy of the glands, 
a far more serious condition than the drivel. Atropia is 
contraindicated. 

Glossodynia occurs occasionally and is probably due to the 
degeneration of the nerve terminals in the tongue. It is a 
paresthesia which does not yield to local treatment. 



Io6 PATHOLOGICAL OLD AGE 

SENILE DEGENERATION OF THE STOMACH 

While the anatomical changes of the stomach, due to the 
process of ageing, are marked, the functional impairment is 
slight, the demands made upon the senile organ being less. In 
senile tissue generally, the functions are performed less actively 
or differently from those of maturity but harmonious relations 
are maintained with allied organs and tissues, the functions of 
which are likewise impaired, thus maintaining the body in the 
state of functional equilibrium. This applies with special force 
to the stomach in which digestion is carried on sufficient for the 
needs of the aged organs while the same anatomical condition 
occurring in maturity would cause serious disturbance. There 
are several natural provisions for shielding the stomach in old 
age from excessive work. There is usually diminished appetite 
due to lessened need for food and to obtunded sense of hunger. 
Owing to the loss of teeth the aged individual cannot chew meat 
and he will take instead, eggs, milk and vegetable proteids which 
are more readily digestible. He has a distaste for flat and in- 
sipid foods and prefers salty and acid ones. The fiat-tasting 
food is generally alkaline and as there is in old age a diminution 
in the quantity of hydrochloric acid, alkaline food interferes with 
digestion. 

The prominent manifestations of senile degeneration of the 
stomach arise from atony and waste of the muscular fibers, 
diminution in the quantity of gastric juice and hydrochloric acid 
and atrophy of the mucous membrane. As a result of these senile 
changes we have atonicity and dilatation of the stomach, weakened 
propulsive power, prolonged retention of food, slow digestion 
of proteids and occasionally also insufficiency of the pylorus. 
Dietetic indiscretions will produce acute indigestion and gas- 
tric asthma and if prolonged, a chronic senile catarrh will result 
which may predispose to cancer. 

Gastric Atonicity 

Etiology. — Owing to the loss of tone of the muscular fibers the 
peristaltic waves are slower, the wave ring of circular fibers 
does not contract as powerfully, contractions of the cardiac 
portion are also slower and less powerful and food is not propelled 
as rapidly toward the pylorus nor is the food mixed as thoroughly 



SENILE DEGENERATION OF THE STOMACH IO7 

with gastric juice. If food has been bolted without proper 
mastication, it may be retained in the stomach for many hours 
or it may pass into the duodenum unchanged. 

While there is a natural loss of tone of muscular fiber in old 
age, this atonicity is increased by overfeeding, by ingestion of 
large quantities of liquids, by swallowing food in lumps, especially 
meats, and by a constant state of mental excitement such as 
worry, rage, etc. 

Symptoms. — The symptoms of atonic dyspepsia are, a 
feeling of distress or bloating lasting for several hours after a 
meal; occasionally heartburn, cramps, nausea, belching of gas. 
Hyperacidity, which is common in younger individuals who then 
complain of acid eructations, is rare in the aged. There is 
usually tympany all over the stomach area and a splashing sound 
can be readily produced over an extensive area. 

The most important physical sign of atonicity is the presence 
of food in the stomach seven hours after ingestion. This is 
determined by washing out the stomach, but the result may 
also be due to hour-glass contraction, pyloric obstruction or 
pylorospasm. Pyloric obstruction in the aged is generally 
caused by a growth; spasm is generally due to hyperacidity 
which is rare in the aged. The hotir-glass contraction of the 
stomach is the result of a healed ulcer and contraction of the 
scar. It is rare in the aged. In pyloric obstruction due to 
growth the pylorus is palpable and peristaltic movements may 
be observed over the stomach proceeding from left to right 
toward the pylorus. In obstruction due to spasm the pylorus 
can be felt during the spasms but not in the intervals. Pyloric 
hypertrophy does not occur in the aged. The differential diagno- 
sis between benign and malignant growths will be considered 
under Gastric Carcinoma. 

Patients suffering from hour-glass contraction following 
ulcer rarely reach old age. Weinstein's test is to give the patient 
some raisins or figs. After two hours the stomach is washed out 
when the seeds will be found. The patient then walks around, 
shakes himself up, then lies down so as to shift the contents of 
the second chamber beyond the contraction to the anterior 
chamber. If the stomach is now again washed out seeds will 
be found that had gone into the second chamber and had been 
regurgitated into the first chamber. 



Io8 PATHOLOGICAL OLD AGE 

In marked pyloric stenosis there is always a marked dilata- 
tion. In senile atony there is generally a slowly developing 
dilatation. 

Treatment. — Normal senile atony will give no distress nor 
will it have any serious detrimental effect if dietetic regulations 
suitable for the aged are carried out. Owing to the normal 
diminution of gastric juice the proteid intake must be reduced, 
or if there is excessive waste of tissue and an increase in pro- 
tein is necessary, pepsin and hydrochloric acid must be given 
with the meal. If the patient has bad teeth the food should be 
comminuted. Food should not be taken in shorter intervals 
than five or six hours. Fat should be excluded as far as possible 
and if given at all, it should not be used for frying foods. Butter 
is the best fat and may be used with bread. Vegetables can 
be taken but the greens should be avoided. Cabbage, lettuce, 
spinach, etc., have little nutritive value and entail much work 
upon the digestive system. 

Fruits raw or stewed are good and spices and condiments 
may be used. Of beverages alcoholics are to be avoided. 

If there is extreme atony, lavage once or twice a week may 
be tried; ordinarily it is not required. Medicinal treatment is 
seldom indicated. Occasional lapses from dietary rectitude 
must be corrected by a brisk cathartic or if there is much 
distress the stomach tube should be used. 

Senile Dilatation of the Stomach 

Etiology. — This is always due to atony and waste of the 
muscular fibers of the gastric wall. It occurs early in those 
who habitually overload the stomach especially among beer 
drinkers, and in those who have an early general arteriosclerosis. 
If these causes do not exist and the individual is careful about 
his food, the dilatation is slight and gives little or no sign of its 
presence. 

Pathology. — The dilatation is usually moderate and involves 
the whole organ, unless the person has been an excessive eater 
when the fundus is greatly dilated. There may be marked 
gastroptosis. The walls of the stomach are thin but the pyloric 
orifice may be hypertrophied. The mucous membrane is thin 
and pale and the glands are atrophied. 



SENILE DEGENERATION OF THE STOMACH IO9 

Symptoms. — In mild cases there are no symptoms. Periodic 
vomiting, which is the most marked symptom of gastric dila- 
tation in maturity, is rare in senility. Eructation of gas occurs 
frequently in beer drinkers and sometimes a small amount of 
fluid is brought up with the gas. Ordinarily there is a Httle 
belching of gas an hour or two after meals or if food is taken 
while the stomach still contains undigested food. Vomiting 
will occur if there is an excessive amount of food in the stomach, 
and some of it is decomposing, producing irritating toxins. 
It may also occur when there is some cause which would pro- 
duce vomiting in other cases, such as shock, hemorrhage, cere- 
bral anemia or an emetic. Clapotage can generally be elicited 
and gurgling can sometimes be felt over the pylorus. Unless 
there is extensive dilatation the physical signs are not marked. 
If the stomach is distended with gas, its outline may be made 
out by inspection and percussion and the fundus can be mapped 
out whenever there is a large amount of food present. 
The most accurate delineation of the stomach is obtained by 
radiography. 

Treatment. — The most important indication in the treat- 
ment of senile dilatation is the regulation of food. The rule 
"Httle and often" is irrational and will make the condition 
worse. Owing to the slowed digestion, food should not be 
given in shorter intervals than five hours. Lavage is necessary 
only if too much or improper food has been taken. A binder 
will relieve the sense of weight following a meal but the benefit 
is psychic rather than physical. Medication is rarely indi- 
cated except perhaps to increase the tonicity of the abdominal 
walls. In such case strychnine in i/6o-grain doses may be 
given, care being taken to avoid excessive stimtilation of the 
heart. Gastroptosis is sometimes reheved by an elastic abdom- 
inal binder. Surgical intervention is not required unless the 
gastroptosis is due to adhesions, bands or similar surgical 
conditions. 



Pyloric Insufficiency 

Pyloric insufficiency is a condition of the pylorus in which 
the orifice is not closed completely or with sufficient force, and 
partly digested food dribbles through. This, in the aged, is due 



no PATHOLOGICAL OLD AGE 

partly to waste of muscular fiber, partly to lessened innervation 
and partly to the weakened reflexes by which the pylorus opens 
and closes. These causes are directly traceable to senile degen- 
eration of the muscular structure and of the plexus of Auerbach 
and to the diminished quantity of hydrochloric acid, which by 
irritating the gastric side of the sphincter causes it to open, and 
when irritating the duodenal side causes contraction and closing 
of the orifice. The only symptom which would indicate the 
presence of pyloric insufficiency is lientery, the stools containing 
particles of protein matter. (This might, however, occur if there 
is a deficiency of gastric juice and the diminished intestinal secre- 
tions are not sufficient to convert the proteids when there is a 
normal quantity of carbohydrates in the food.) This condition 
is sometimes detected after death. Treatment is the same as 
in gastric atonicity. 

SENILE DEGENERATION OF THE INTESTINES 

Pathology. — The degenerative changes in the intestines in- 
clude atony and waste of the muscular fibers, thinning of the 
walls, with atrophy of the glands, the folds are smoothed out, 
and occasionally there are hernial protrusions and diverticulae. 
Feces collect in the colon distending that portion of the intestines 
and the rectum and the wasted muscular fibers cannot overcome 
this distention. The colon consequently becomes dilated form- 
ing a pouch which may be 3 to 4 inches in diameter. There is 
lessened peristalsis, diminished intestinal secretion and lessened 
reflex irritability. As a result of these changes senile consti- 
pation is produced. 

Senile Constipation 

Etiology. — This is a symptom of senile degeneration of the 
intestines. The following causes contribute to this condition: 
(i) Diminished peristalsis due to atonicity of the intestinal 
walls; (2) diminished intestinal secretions due to atrophy of 
the intestinal glands; (3) diminished reflex irritability due to 
lessened innervation; (4) diminished bile supply thereby in- 
creasing the tendency to thickening of intestinal mucus and the 
formation of mucomembranes ; (5) unsuitable food; (6) causes 
connected with gastric and duodenal digestion. Other causes 
of constipation as tumors, adhesions, hemorrhoids, viscerop- 



SENILE DEGENERATION OF THE INTESTINES III 

tosis, habit, indigestion, etc., do not produce the condition here 
described which is simply a manifestation of senile degeneration. 

S5nnptoms. — Senile constipation comes on slowly, the pa- 
tient finding a gradually lessened desire for stool. If he is accus- 
tomed to go to stool at the same time daily, he must make a 
sensible effort to expel it and at times nothing will pass in spite 
of all straining. The stools are small and hard, dark and dry 
if they have been long retained, or light, clayey, if there is an 
abnormal deficiency of bile. Occasionally there is impaction of 
the colon with a canal through the impaction. When this is 
present the stools pass as small, hard balls. We can have a 
senile constipation with a daily evacuation; this seeming para- 
dox occurs only when the feces are retained in the bowels be- 
yond the normal period. In this condition the stools are hard, 
dark and dry and particles of food will be found that had been 
ingested two or three days before. In colonic or rectal impac- 
tion there is a sense of weight or fulness in the pelvis and a 
feeling or desire for a stool which does not pass upon straining. 

Treatment. — In dealing with senile constipation we must 
take into consideration the various causes. There may be 
simply a dyschezia or inability to expel the feces from the colon 
and rectum. In this condition enemas are required and if the 
lower gut is impacted, the hard feces must first be softened by 
a prolonged high enema, of warm water containing a small 
amount of bicarbonate of soda. If this will not remove the 
mass it must be scooped out. It is sometimes possible to in- 
crease the expelling force by lowering the seat of the closet or 
raising the feet upon a foot stool. Cool rectal douches are often 
serviceable and in some cases rectal bougies containing ergotin 
and strychnine will increase the tonicity of the rectal walls. 
Astringent enemata will contract the rectal pouch, thereby 
lessening the tendency to impaction but they will not increase 
the expulsive power of the bowel. If the trouble lies solely in 
the lower bowel, cathartics are useless. In most cases the ato- 
nicity extends throughout the whole length of the intestines and 
then peristaltic stimulants are required. The most powerful 
of this class of drugs is a hypodermic injection of Eserin i/ioo 
gr. or aloes by mouth which increases peristaltic activity from 
the stomach to the sphincter-ani and produces a soft stool. 
The main objection to aloes is its tendency to cause congestion 



112 PATHOLOGICAL OLD AGE 

of the lower bowel and to produce hemorrhoids. It gripes but 
this can be overcome by combining rhubarb with it. Bella- 
donna which is usually added to overcome the griping effect is 
contraindicated as it lessens peristalsis. Other peristaltic stimu- 
lants are: cascara, senna, podophyllum, leptandrin and the 
bile salts. Rhubarb produces large, soft stools and it can 
be taken for years without causing habituation. It has a mild 
peristaltic effect and it increases the activity of the intestinal 
glands. 

Leptandrin and podophyllum gripe and are inferior to 
senna, aloes, and cascara unless a hepatic stimulant is required 
at the same time. If there is a deficiency of bile it is better 
to supply this deficiency by using the bile salts instead of em- 
ploying other hepatic stimulants, since the bile salts themselves 
also increase hepatic activity. Intestinal peristalsis is normally 
induced by the presence of indigestible portions of food, which 
act as a mild irritant to the bowels, and insufficiency of such 
matter lessens normal peristalsis. In old age there is a waste of 
the muscle fibers which produce peristalsis and there is probably 
a degeneration of nerve cells in the intestines. More powerfiil 
stimulation or irritation of the intestines is required to increase 
motility and this can sometimes be brought about by increasing 
the amount of food refuse and cellulose. As the ordinary foods 
containing much cellulose do not contain sufficient nutritional 
elements unless given in large amounts, a combination of readily 
digestible concentrated foods and substances containing little 
food matter and much cellulose is indicated. Spinach, cabbage, 
cauliflower, turnips, beets and carrots contain much cellulose. 
Rice and sago are constipating but other farinaceous foods may 
be taken. Fresh, tender, well-done meats may be taken, but 
meats that have been in cold storage should not be used, and 
this applies not only to constipation but to all senile conditions. 
Fresh boiled fish can be taken ad libitum. Whole wheat, 
graham and brown bread, and toast are good. Milk con- 
stipates many persons but buttermilk does not. Tea and 
spirituous liquors should be avoided. Pork, liver, mut- 
ton, all smoked and preserved meat and fish, cheese, 
pastry, sweets, eggs and nuts are objectionable. A glass of 
cold water at bedtime and a glass of hot water containing a 
pinch of salt or a teaspoonful of any of the cathartic salts will 




Fissure in ano. (From Gant's "Constipation.") 



SENILE DEGENERATION OF THE INTESTINES II3 

help to flush the bowels. Large doses of salts should not be 
used as they withdraw water from the organism which the body 
cannot spare. Only in the obese are the salines of service. 

Mechanical measures such as manual massage, massage by a 
mechanical roller, coarse vibration will sometimes relieve this 
condition. They act either by direct propulsion of intestinal 
contents or by producing a mild irritation and consequent 
peristalsis. 

Among the most annoying concomitants of senile constipation 
are flatulence and coliky pains which are produced by the intes- 
tinal gases. These can be avoided by taking occasionally 5 -grain 
doses of charcoal. As the loss of tonicity and diminished glandu- 
lar activity in old age cannot be removed permanently a cure 
of senile constipation is impossible. Much can, however, be 
done by occasional stimulation of intestinal activity, by emptying 
the colon and rectum by means of enemata whenever there is a 
feeling of fulness, by adhering to a fixed hour for stool, using a 
low seat or foot rest to secure a more favorable position for 
defecation, and by careful control of the diet. 

Atony of the Sphincter Ani 

Atony of the anal sphincter is occasionally found in the aged 
as part of the general loss of tonicity of the intestines. The 
patient finds that he must make a sensible effort to close the 
sphincter after defecation and it requires an effort to keep it 
closed when there is desire for stool at an inopportune time. 
Small amounts of feces dribble out unconsciously and his clothes 
are constantly soiled, and when expelling flatus from the bowels 
he cannot control the passage of feces at the same time. If 
internal hemorrhoids exist they protrude from the anus. An 
effectual treatment of this condition is the occasional inunction 
of the sphincter with nut gall ointment to which 10 per cent, of 
ergotin is added. The base should be lanoline. Other astring- 
ents may be used but they may cause contraction of the rectal 
walls and constipation. 

Anal Fissure 

Anal fissure, while not a degenerative process, is frequently 
found in the aged, associated with atony of the sphincter. 
With the waste and atony of the muscular fibers, atrophy of 
8 



114 PATHOLOGICAL OLD AGE 

mucous membrane and changes in the skin immediately surround- 
ing the anal orifice, slight causes will suffice to produce fissures 
in and about the sphincter. Hardened feces or the sudden 
expulsion of feces or scratching are the most frequent causes of 
this distressing lesion. The fissures themselves are generally 
very small, even microscopic, and when visible appear like short 
scratches about the sphincter. They may extend to the sub- 
cutaneous tissue and are then painful, otherwise they cause a 
pruritus which is aggravated by defecation. They do not heal 
readily as the passage of feces causes frequent irritation and the 
intolerable itching causes scratch lesions which may become 
eczematous or infected. A 2 per cent, cocaine solution will 
temporarily relieve the itching and a zinc ointment with a petro- 
latum base will prevent irritation and may effect a cure. 

SENILE DEGENERATION OF THE LIVER 

Senile degeneration of the liver is part of the general process 
of involution and is usually associated with and due to arterio- 
sclerosis of the hepatic artery. Cases are occasionally found, 
however, in which the liver is degenerated while the artery is 
unimpaired. 

Pathology. — The senile liver resembles the liver in the atrophic 
stage of cirrhosis. If there is no disturbance of the general circu- 
lation the organ is lighter in color than in maturity, but as there 
is usually some impairment of the circulation causing passive 
hyperemia the color is dark brown and dotted sometimes with 
yellowish spots of fat deposits. The organ is contracted, the 
acini are compressed through proliferation of the connective 
tissue and the capsule is thick, opaque and closely adherent to 
the body of the gland. The suspensory ligaments are weakened 
and this with a flaccid diaphragm, and with changes in the chest 
wall permits a ptosis of the organ with displacement to the left. 

Symptoms. — The only marked symptom is the intestinal 
disturbance due to diminution of bile secretion, the stools being 
foul-smelling and light in color. If the bile is insufficient to 
emulsify the fat ingesta, fat globules will be found in the feces. 
Percussion elicits a diminution in the size of the organ and a 
probable ptosis with lateral displacement. It is sometimes 
possible to feel the upper border below the ribs while the tense 



SENILE DEGENERATION OF THE LIVER II5 

lower border can sometimes be felt below the umbilicus. It is 
not tender upon pressure and it gives none of the usual symptoms 
of cirrhosis. If jaundice is present it is invariably due to occlu- 
sion of the bile duct or to some pathological state of the gall- 
bladder. 

Treatment. — Treatment is rarely indicated. The diminished 
amount of food taken by the aged requires a diminished amount 
of bile and it is only when this diminished quantity is insufficient 
— as evidenced by light-colored stools — that anything need be 
done to stimulate the functions of the organ. By far the best rem- 
edy in this condition is inspissated ox gall in 5 -grain doses two 
or three times a day. This acts as a hepatic stimulant, causes 
a more fluid bile and at the same time supplies the deficiency 
of bile in the intestines. Other cholagogues like calomel, sodium 
succinate, sodium sulphate, sodium salicylate, benzoic acid and 
the many vegetable drugs may be given but none equals the 
natural bile salts. 

SENILE DEGENERATION OF THE GALL-BLADDER 

Senile degeneration of the gall-bladder is important on account 
of its interference with the secretion of bile and on account of 
secondary effects caused by retention of bile and formation of 
gall-stones. 

Pathology. — The walls of the gall-bladder become thickened 
and rigid through thickening of the fibrous coat. This also 
diminishes the cavity of the gall-bladder and a contraction of the 
walls causes a diminution in the size of the organ. Occasionally 
there are lime deposits in the walls and a layer of inspissated 
cholesterin lining the cavity has been reported. The neck is 
contracted, the lumen of the cystic duct is diminished and in 
rare cases it is entirely obliterated. The common duct is usually 
dilated. 

The amount of bile is diminished and it contains more choles- 
terin than in maturity, the secretion becomes jelly-like and fre- 
quently hardens, forming gall-stones. These may give rise to 
cholecystitis and the usual symptoms of gall-stones. 

Symptoms. — Degeneration of the gall-bladder gives no 
symptoms unless the gall-stones increase in size or number so as 
to cause local inflammation, or move toward the duodenum 



Il6 PATHOLOGICAL OLD AGE 

when they may produce the familiar symptoms of choleHthiasis. 
Complete occlusion of the cystic duct may occur without 
marked symptoms, the bile flowing from the liver through the 
hepatic and common ducts to the duodenum. If, however, the 
common duct is occluded there is jaundice and the intestinal 
symptoms of deficient bile secretion are produced, such as clayey, 
foul-smelling stools containing fat globules. It is often impossi- 
ble to determine whether the deficiency of bile in the intestines 
is due to the liver, cyst or ducts as it may be caused by a 
diminished formation, a change in the character of the secretion 
or an obstruction to the flow. If there is obstruction and con- 
sequent jaundice, the fault lies in the ducts. A change in 
character may arise in the liver but is more probably due to 
prolonged retention in the gall-bladder. This may give rise 
to occasional colicky pains but the diagnosis cannot be positively 
made until the symptoms of cholecystitis or cholelithiasis appear. 
Treatment. — The only medical treatment applicable to 
degeneration of the gall-bladder has for its purpose the 
production of a more fluid and a more copious flow of bile, as has 
been recommended under the treatment of degeneration of the 
liver. This has no effect upon the degeneration itself, but it 
enable the organ to perform its functions more readily and 
prevents irritation and inflammation. If cholecystitis or chole- 
lithiasis occurs, surgical intervention is necessary. 

SENILE DEGENERATION OF THE KIDNEY 

The senile contracted kidney is the physiological kidney of old 
age and is mentioned here only because pathologists frequently 
report the finding at autopsies of chronic interstitial nephritis 
that gave no symptoms during life. 

The senile anatomical changes have been described. They 
differ from the pathological changes found in nephritis in the 
absence of hyaline and fatty degeneration and of cloudy swelling 
in the tufts and vessels. The epithelium of the tubules shows 
no change and the tubules are clear and free from the granular 
detritus which generally obstructs the tubules in nephritis. 

Symptoms. — The only symptoms of senile contracted kid- 
ney are a trace of albumin in the urine which may persist during 
life and a diminished secretion of urine. The specific gravity 




Senile Contracted Kidney. (Pic and 
Bonnamour.) 




^•^^ 



Senile Bladder showing also hypertrophied prostate. (Pic and 
Bonnamour.) 



SENILE DEGENERATION OF THE BLADDER II7 

of the urine is normal or but slightly decreased, the urates are 
considerably diminished and calcium salts also are generally 
diminished. The diminution of the urates and calcium salts 
is, however, not due to the kidney changes but to metabolic 
changes and only the diminished quantity of urine of normal or 
slightly decreased specific gravity and a persistent albuminuria 
without casts are indicative of senile contracted kidney (see Chronic 
Interstitial Nephritis). 

Treatment. — Nothing need be done unless the amount of 
urine is markedly diminished when drinking large quantities 
of alkaline mineral water will be found effective. Other diuret- 
ics are rarely required. 



SENILE DEGENERATION OF THE BLADDER 

Etiology. — While dilatation of the bladder through atony of 
the muscular coat is part of the normal process of involution the 
condition is aggravated through the retention of urine. Thus 
one of the many vicious circles of senility is produced. The 
atonicity of the organs permits retention of urine which further 
distends the bladder, further stretching and weakening the mus- 
cular coat, and this in turn permits greater retention and disten- 
tion. A frequent cause of retention of urine is a hyper- 
trophied prostate which obstructs the free passage of urine. 
In some cases the diminished sensitiveness and irritability of 
the organ makes the need for micturition less strongly felt and 
the aged individual neglects it. 

Pathology. — The pathology is an exaggeration of the normal 
senile changes. There is atony and waste of the longitudinal 
muscular fibers and of most of the circular fibers. Some of the 
latter degenerate into fibrous bands which contract, and the 
weakened wall bulging out between these contracted bands 
forms rugas, pockets and pouches. The mucous membrane 
becomes atrophied, the whole organ is dilated and its contrac- 
tility is lessened. In rare cases the contractions produced by 
the fibrous bands may be so numerous or extensive as to diminish 
the capacity of the organ . There is usually atony of the sphincter 
due to waste of the muscular fibers and sometimes to pressure 
of an enlarged prostate. 



Il8 PATHOLOGICAL OLD AGE 

Symptoms. — The earliest symptom of degeneration of the 
bladder is a diminution in the expulsive power of the organ. 
The patient cannot send the stream as far as formerly. Then 
he finds that it requires a sensible effort to void the urine, that 
it takes a few moments of straining before the flow appears and 
instead of coming out with force, it is sluggish. Later the 
stream is small and drops from the meatus. After the bladder 
has become dilated there is retention of urine and in addition 
to the other symptoms there is a frequent desire to urinate, 
especially at night, and if there is atony of the sphincter the 
patient may wet the bed. There is generally a sense of weight 
in the pelvis, relieved after the bladder is emptied. Dribbling 
is always due to atony of the sphincter. Occasionally there is 
constant dribbling, the urine flowing away as soon as it en- 
ters the bladder from the ureters. If there is marked aton- 
icity of the bladder and sphincter there may be retention and 
incontinence. 

Diagnosis. — The diagnosis of dilatation of the bladder and 
atony of the sphincter are readily made but care must be taken 
to eliminate other factors which may cause these symptoms. 
There may be retention without atonicity — due to stone, tumor, 
hypertrophied prostate or an old stricture. In such case there 
will be difliculty in starting the flow, but after it is started it 
comes out with force whether coming naturally or if drawn off 
with a catheter. 

If due to stone the trouble is worse when the patient is 
much on his feet; if due to enlarged prostate the difliculty is 
more pronounced at night or in the early morning. A positive 
diagnosis is made by means of rectal examination, sound and 
cystoscope. This also applies to growths. Dribbling or pass- 
ing a few drops of urine after urination is apparently completed 
is evidence of atony of the sphincter. If after catheterization 
the patient is laid upon his back, then turned upon his face and 
made to arise, the desire to urinate or the presence of more 
urine upon an immediate recatheterization shows the presence 
of retained urine in the vesical pouches. These may be minute 
and hold not more than a drop or two in each pouch but when 
these drops are long retained they decompose, cause local irri- 
tation and inflammation. A distended bladder can readily be 
made out by palpation and percussion and confirmed by the 



SENILE DEGENEIL\TION OF THE BLADDER II9 

catheter. Without this confirmation it may be mistaken for 
ascites. Occasionally the insertion of the catheter will excite 
urethral spasm which may be mistaken for some other form of 
obstruction. An injection of a 2 per cent, solution of cocaine 
in warm water will relieve spasm but not organic obstruction. 
The character of the urine gives us little information. A reten- 
tion urine is ammoniacal, due to decomposition, and is turbid. 
If the turbidity is not cleared up by heat it is due to bacteria ; 
but bacterial urine is frequently found in the aged without 
discernible cause or ill effects. Pus and blood in the urine may 
be due to vesical disease but they do not occur in uncomplicated 
senile degeneration. 

Treatment. — In the treatment of senile bladder affections 
the first indication is to empty the bladder and secure an evacua- 
tion of it at intervals of not more than eight to twelve hours. 
The patient should be impressed with the necessity of attend- 
ing to the demand for evacuation of the bladder without delay 
and if he feels that he has not passed all, he should get on his 
knees and press the edge of the vessel against the perineum. 
If catheterization becomes necessary the patient should be 
taught how to use it and how to sterilize it. The sterilization 
must be repeatedly insisted upon until it becomes a habit, as 
the aged become forgetful and careless, the few drops of urine 
remaining in the catheter decompose and with the next inser- 
tion bacteria are introduced into the bladder. Internal medica- 
tion has two objects, the prevention of decomposition and the 
increase of tonicity. If there are other pathological conditions 
present these require treatment apart from the treatment for 
atonicity. Decomposition is prevented by the use of hexa- 
methalenetetramin which appears on the market under various 
trade names, urotropin, formin, cystogen, uritone, etc. The 
dose is 5 grains twice daily, always to be given in solution. No 
other urinary antiseptic approaches this in efficacy. To in- 
crease the tonicity of the organ, str^^chnine and electricity will 
be found beneficial. Belladonna which is almost a specific in 
incontinence of uri.ne in childhood aggravates the senile atony 
of the sphincter. If there is no arteriosclerosis ergot can be 
given in doses of 15 minims of the fluid extract three times a 
day. If there is arteriosclerosis with high blood pressure its 
powerful vasoconstrictor effect may cause cerebral trouble. 



I20 PATHOLOGICAL OLD AGE 

Aloes has been recommended on account of its property to 
stimulate peristalsis thereby increasing the activity of the 
muscle fibers. This action is directed more particularly to the 
lower intestinal tract and it has little if any effect upon the blad- 
der. The injection of astringents and mild silver solutions have 
sometimes a temporary beneficial effect. A single disten- 
tion will undo all the good that may have been achieved by 
treatment. 

SENILE DEGENERATION OF MALE GENITALS 

Senile Impotence 

The male reproductive organs undergo profound anatomical 
changes, out of all proportion to the functional changes that 
occur in old age. 

Pathology. — The testes are atrophied, the fibrous coat is 
thickened, there is a proliferation of connective tissue through- 
out the gland, compressing the lobules and their seminiferous 
tubes, some of which are completely obliterated, while in others 
the lumen is compressed and occluded. The vas deferens is 
hardened and thickened, its caliber is diminished and the 
seminal vesicles are atrophied. The semen becomes more fluid 
and transparent, while in some pigment is deposited giving the 
semen a brown color, and the spermatozoa are diminished in 
number but their functional activity is not impaired. Active 
semen has been found in the tenth decade of life. 

The penis is shrunken, the glans hardens and the whole 
organ becomes less sensitive. The skin of the penis and scrotum 
undergoes the same changes that occur in other parts of the 
body and in addition the whole genital region becomes pig- 
mented and there is often a fetid bromidrosis. 

Functional Changes. — Diminution both in sexual desire and 
power of erection is generally noticed during the fifth or sixth 
decade and these are the principal manifestations of the male 
critical period; in many cases, however, there is apparently 
little or no loss of functional activity. Where diminishing libido 
and potentia proceed together the impairment may not be 
noticed, since neither mental nor physical distress is produced. 
It is only when attention is called to the lessened functional 
powers — as by marriage with an erotic woman — that the condi- 



SENILE DEGENERATION OF MALE GENITALS 121 

tion is recognized. In some cases the desire remains after the 
power of erection has waned, a condition frequently found in 
confirmed masturbators. 

Treatment. — The treatment of senile impotence depends 
upon the general physical condition of the individual and attend- 
ing circumstances. In cases where there is a gradual diminu- 
tion in erectile power and a diminution in desire nothing need 
be done unless marriage is contemplated. We must bear in 
mind that the intense mental and physical exertion during 
coitus, and the succeeding depressing reaction are detrimental 
to the aged individual and if there is uncompensated heart 
disease a fatal result may ensue. Where the desire remains 
but the power is lost it is often difficult to decide whether 
aphrodisiac or anaphrodisiac measures shall be employed. 
The object of treatment in such cases is to diminish the libido 
and at the same time slightly increase the potentia in order to 
produce a favorable psychic effect. The patient's wish is to 
have the power of erection restored and he will not wilhngly 
follow any treatment which will lessen the desire. It will 
therefore be necessary to resort to anaphrodisiac drugs such as 
bromides, monobromated camphor, valerian and lupidin, and 
at the same time use local stimulants, warm applications, 
massage and electricity. The water applications and massage 
have only a momentary effect, still sufficient to satisfy the 
patient. As the frequency and the intensity of the hbido 
diminish under above drug treatment, local stimtilation can be 
lessened and finally omitted entirely. Electrical stimulation 
by means of the f aradic current is more permanent but it should 
not be employed unless the other measures fail or a prolonged 
effect is desired. Local irritation, as from a hypertrophied 
prostate, may keep up the hypererosis. Lascivious literatin-e, 
pornographs, the goading and teasing of thoughtless friends, 
all tend to keep the mind directed to the impaired function. 
The removal of every source and form of erotic stimulation is 
necessary for success. If aphrodisiac treatment is desired, the 
above-mentioned local measures should be employed and in 
addition the ordinary aphrodisiac remedies may be given 
internally. Ergot which is probably the best drug for func- 
tional impotence cannot be used in senile cases on account of 
its vasoconstrictor effect. Phosphorus or zinc phosphide with 



122 PATHOLOGICAL OLD AGE 

nux vomica are reliable aphrodisiacs but the action is not 
permanent and constantly increasing doses must be given. 
Sandalwood oil in lo-minim doses three times a day is some- 
times effective. Damiana and muirapuama are of little use in 
the aged while yohimbin, recommended as an aphrodisiac, is 
an irritant to the genital organs, the irritation producing the 
erection. A lymph compound consisting of lymph, lymphatic 
gland extract, brain and cord extracts from goats and orchitic 
fluid from bulls has been reported effective in some cases. 

Psychic measures usually give immediate and often lasting 
results, marriage with a young person being sometimes fol- 
lowed by happy results without other treatment. Association 
with young persons, flattery by a person of the opposite sex, 
sensuous pleasures, all tend to bring about the desired effect. 

Senile satyriasis, inordinate erotic desire, occurs occasionally 
in the aged. The bromides in large doses will cure this condi- 
tion. If occurring as a recrudescence after years of quiescence, 
it is a symptom of senile dementia. It then usually appears 
during the senile climacteric and may lead to acts of violence. 
Bromides and narcotics are required. Threats are useless. 

SENILE DEGENERATION OF THE PROSTATE 

The senile changes in the prostate are hypertrophy and 
atrophy of the gland. Hypertrophy, which is found in about 
one-third of all cases, is an anomaly in senile involution as it is 
the only case presenting an increase of glandular tissue as a 
senile change. Many theories have been advanced for this 
peculiarity; none is satisfactory. A rational explanation may 
be found in the theory of tissue-cell evolution advanced in this 
work. 

Pathology. — The hypertrophy assumes various forms. Some- 
times the whole gland is enlarged, occasionally it is limited 
to one or both lateral lobes, more often the middle lobe is 
larger than the others. In most cases the hypertrophy con- 
sists of glandular, muscular and fibrous elements, the latter 
two predominating. Occasionally the glandular element is 
greater, producing a soft hypertrophy. The mass is generally 
unsymmetrical, may reach the size of a hen's egg and con- 
tains numerous small fibrous tumors, which in connection with 



SENILE DEGENERATION OF THE PROSTATE 1 23 

prostatic concretions frequently block up the ducts. If the 
hypertrophy is lateral it twists the prostatic portion of the 
urethra and if central it flattens and compresses the canal. 

Symptoms. — While cases have been recorded in which pros- 
tatic hypertrophies have been found which gave no symptoms 
during life this condition usually gives early evidence of its 
presence. The old man finds that he must urinate more fre- 
quently, especially at night, that he must make a sensible effort 
to start the flow and that it comes in a small stream without 
any force behind it. Later on, there is a feeling of uneasiness 
or of dissatisfaction as if he had not been able to completely 
empty the bladder and he wants to pass a little more. There 
is always an amount of residual urine in the bladder which 
decomposes and may produce cystitis. After a time there is 
retention of urine with dilatation of the bladder, still later the 
atony of the sphincter induced by the senile waste of the muscle 
fibers or by paralysis caused by pressure, permits dribbling and 
we have retention with incontinence. There is now atony and 
dilatation of the badder with retention of decomposing urine, 
atony or paralysis of the sphincter, the lumen of the upper part 
of the urethra being diminished and perhaps twisted, and 
owing to the size of the gland it is forced upward carrying the 
neck of the bladder with it. Urination is now impossible with- 
out the catheter and catheterization must be performed two 
or three times a day. A frequent complication is septic bac- 
terial infection produced by the catheter. Urosepsis from this 
source leads to a train of septic inflammations beginning with 
urethritis and cystitis and involving allied organs and tissues 
\mtil pyelitis and exhaustion terminate life. The diagnosis of 
prostatic hypertrophy may be made by rectal examination 
in the knee-chest position. The only conditions which present a 
growth or tumor in the locality of the prostate are cancer and 
stone. Cancer gives the symptoms of cachexia, hematuria and 
pain. Calculus is movable and its diagnosis can be confirmed 
by the searcher and cystoscope. 

Treatment. — The excellent results achieved in recent years 
by partial and total prostatectomy and the unsatisfactory 
results of medical treatment have removed prostatic hyper- 
trophy from the field of the physician to that of the surgeon. 
Shall it be a complete or a partial removal of the mass, shall it 



124 PATHOLOGICAL OLD AGE 

be extirpation or enucleation, suprapubic or perineal, shall it be 
performed early or late ? Each has its advocates and opponents 
and each has been successful. Every surgeon has his favorite 
method of operation and judging from results there is little to 
choose between them. Perineal enucleation seems to have a 
lower mortality but more frequent unfavorable after-ejffects, 
such as fistulas, strictures, incontinence, etc. As for the time 
when the operation shall be performed some advise it before 
the catheterization habit has been formed, others favor it when 
the catheter fails to remove the residual urine, others again will 
not operate except as a last resort. Bottini's galvano-cautery 
operation has not given the favorable results in the hands of 
his followers that he has reported in his own cases. Local 
applications, formerly much in vogue, have fallen into disuse. 
The only drugs from which any improvement has been reported 
are iodine, silver and mercury, yet real benefit from either has 
been rarely recorded. Straightening and stretching the tire- 
thral canal by means of sounds has relieved the dysiuia but has 
no effect upon the prostate. If catheterization becomes neces- 
sary the old man should be taught how to use the catheter and 
how to sterilize it. He generally becomes more expert in the 
introduction than the physician himself, but there is some 
danger that in his hands it will lead to sexual perversions. The 
family should look after the sterilization of the instrument and 
this should be performed immediately before and after its use. 
Atrophy of the prostate is the form of degeneration that is 
analogous to the senile degeneration in other glandular organs. 
It occurs in about lo per cent, of the cases. It is only of im- 
portance when the proliferated fibrous bands constrict the 
prostatic portion of the urethra and interfere with the free flow 
of urine. In that case sounds should be used to dilate that 
portion of the canal while the catheter is used to draw off the 
urine. In extreme cases surgical measures must be resorted to 
to relieve the ischuria. 

SENILE DEGENERATION OF THE FEMALE GENITAL 

ORGANS 

The senile degeneration of the female genital organs gener- 
ally occurs during the middle or close of the fifth decade. The 
anatomical and physiological changes are well marked, proceed 



i 




Progressive stages in Prostatic Hypertrophy; Semidiagrammatic. (Squier, Medical 
Record, Feb. 3, 1912.) 



SENILE DEGENERATION OF THE FEMALE GENITAL ORGANS 1 25 

rapidly and are accompanied by constitutional symptoms and 
often by pronounced changes in the entire organism. The 
external genitals atrophy, the labia are shrunken, flabby and 
do not completely close the vulvar aperture leaving the vaginal 
orifice exposed. The skin is dark, wrinkled and leathery; the 
hair thin and gray. The vagina is wrinkled, dry, easily dilated 
and owing to the loss of tonicity of its walls, the latter fall 
together. Occasionally the vagina shrinks, its caliber is dimin- 
ished and there is a progressive atresia. The uterus undergoes 
atrophy with marked histological changes. The atrophy pro- 
ceeds rapidly during the period of the menopause then con- 
tinues slowly during the rest of life, finally falling below the 
weight and size of the uterus at puberty. The walls contract, 
diminishing and occasionally obliterating the cavity. The cer- 
vix becomes elongated. In some cases annular or partial con- 
strictions of the walls of the cervix and body cause a series of 
dilatations or completely enclosed cavities. The mucous mem- 
brane is smooth, but occasionally it is covered with minute 
nodules, the remnants of glands. The external coat of the 
uterus is usually tough, leathery and wrinkled. The muscidar 
coats atrophy, there is a hyperplasia of fibrous connective 
tissue and the elastic fibers gradually disappear. The blood- 
vessels degenerate and may become obliterated. The Fallopian 
tubes become obliterated and appear as strings on the border 
of the broad ligaments. The ovaries atrophy, become hard, 
dense, sometimes containing calcareous deposits, rarely cal- 
careous incrustations. The ovaries shrivel and have a rough 
knobbed appearance after the menopause but late in life they 
become smooth and flattened. The histological changes are 
similar to the changes in other soHd organs, a waste of muscle 
and elastic tissue and a hyperplasia of connective tissue. The 
Grafiian follicles degenerate into minute nodules or disappear 
leaving cavities. 

The essential physiological change is the cessation of men- 
struation. Incidental thereto is atrophy of the mammary 
glands with the disappearance of milk and followed generally 
by neuroses and sometimes psychoses. 

While the menopause and the discomforts incident thereto 
are physiological, the latter may be so pronounced as to require 
medical intervention. 



126 PATHOLOGICAL OLD AGE 

The menses may cease suddenly or they may appear at 
irregular intervals before their final disappearance. Nothing 
can or need be done to bring them on although women fearing 
that delayed menstruation means pregnancy, will often insist 
upon doing something to cause their reappearance. A persist- 
ent sanguineous discharge between the menstrual periods is 
indicative of a grave uterine disorder, frequently a malignant 
growth. It may be due to inflammation or traumatism pro- 
duced by instruments used to produce abortion. 

The uncomfortable sensations, flushing of the face, a feeling 
of heaviness or uneasiness, occasional disinclination for work 
and at other times excessive activity, irritability, etc., that 
accompany the menopause can often be relieved by the use of 
dried corpora lutea given in lo-grain doses several times a day. 
This should be discontinued as soon as its therapeutic effect is 
produced and resumed when the disagreeable sensations return. 
The flushes and headache can be speedily relieved by a hot foot 
bath. An intolerable vulvar pruritus is sometimes present and 
can be temporarily relieved by a 2 per cent, cocaine solution or 
ointment. 

The neuroses and psychoses that accompany the menopause 
are often intractable but they usually disappear at the comple- 
tion of the period. Irritability with occasional violent, uncon- 
trollable outbursts of temper, and hysteria may occur. These 
are best treated by bromides and chloral. Hyoscine given 
hypodermically in i/ioo-grain doses will generally quiet the 
patient during the violent attack. In many cases, however, 
the outburst of temper lasts but a few moments and is followed 
by hysterical tears or by a sound sleep and no treatment is 
required. Women sometimes know when these attacks will 
come on, they know or feel that they will have a bad day and 
while some will try to fight off the approaching feeling of irrita- 
bility, others give vent to their feelings and refuse every effort 
to relieve them. The treatment of these cases depends to a 
great extent upon the temperament of the individual and psychic 
measures are often more effective than drugs. The menopause 
usually produces a profound psychic depression in childless 
women. Moral suasion is occasionally effective in these cases 
but drugs are useless except to produce a momentary stimulation. 

Atresia of the senile vagina seldom produces much discomfort 



SENILE DEGENERATION OF THE DUCTLESS GLANDS 1 27 

and this condition may pass unnoticed unless discovered acci- 
dentally. There may be a local or annular constriction, more 
often the diameter of the canal is diminished throughout its 
length. In a few cases the constriction is sufficient to interfere 
with the free^ discharge of the uterine and vaginal secretions, 
and in rare cases the occlusion is complete, preventing the dis- 
charge entirely. There is very little secretion from these parts 
in the aged, virtually none when the woman is in the recumbent 
position. When walking a slight mucous discharge appears. 
The retention of this discharge will produce a catarrhal vaginitis 
and may cause a metritis ; occasionally it becomes mucopurulent 
and may then lead to local septic infection. The treatment 
depends upon the extent of the atresia. Omitting the atresias 
due to cicatrical tissue and other surgical growths, conditions 
which are not considered here, atresia of the vagina in the aged 
seldom requires treatment. In some cases astringent injections 
will serve to diminish the discharge and it is often possible to 
dilate the canal with the finger. For localized constriction a 
tampon with boroglyceride will usually be effectual. In the 
rare cases of complete occlusion surgical intervention is necessary. 

SENILE DEGENERATION OF THE DUCTLESS GLANDS 

Neither the anatomical nor the physiological senile changes 
in these glands are well understood. While they generally 
undergo atrophy, hypertrophy is occasionally found, yet there 
does not seem to be any marked perversion of function in either 
case. Pic says, the senile changes explain the lessened resistance 
to infection and intoxication, yet the aged have apparently 
increased resistance to many forms of infection since infectious 
diseases except erysipelas are relatively less frequent in them 
and when they do occur they are usually milder, and autoin- 
toxications are also borne better. Lorand ascribes the senile 
changes mainly to atrophy of the thyroid gland yet thyroid medi- 
cation will not retard the changes. From our limited knowledge 
of the internal secretions and their intimate interrelations, increas- 
ing or diminishing the work of each other, it is probable that so 
long as they maintain their functional relations to each other the 
harmonious relations of the whole organism are maintained. 
This of course presupposes that other organs are not impaired. 



128 PATHOLOGICAL OLD AGE 

Atrophy of the ductless glands lessens their secretions and conse- 
quently their functional activity but counteracting influences, as 
the vasomotor action of the suprarenals and thyroid, prevent a 
disturbance in their action. In some cases excessive atrophy 
in one gland is compensated by increased activity in others as 
may occur when the spleen is greatly atrophied and the lym- 
phatic glands become enlarged. Lacking, however, more definte 
knowledge of the functions of the ductless glands and especially 
of their functions when they have undergone senile degenera- 
tion, work in this direction must be based upon hypothetical 
assumptions and animal experimentation which leave a wide 
margin for faulty conclusions. 

Spleen. — The spleen is generally atrophied, and its weight 
is greatly reduced, weighing as little as 40 grams instead of 100 
to 150 grams, the normal weight in maturity. The Malpighian 
corpuscles are correspondingly atrophied, the fibrous tissue is 
increased and the walls of the arterioles are considerably thick- 
ened, while the arterioles themselves may be completely obliter- 
ated through pressure or constriction produced by fibrous bands. 
The color ranges from bright red to red brown. The capsule 
is closely adherent, thick, rough, opaque, the organ presenting 
the appearance of a withered apple. In some cases the spleen 
is found hypertrophied but in these cases there can usually be 
obtained the history of a disease with which splenic hypertrophy 
is associated. 

In cases of extreme atrophy the spleen consists of a mass of 
fibrous trabeculi in which particles of spleen substance are en- 
trapped, and in which most of the blood-vessels are obliterated. 
Notwithstanding these profound changes there is apparently 
no change in the functions of the organ. It may be, however, 
that there is a compensating increase in the functions of the 
lymphatic glands, as total extirpation of the spleen in maturity 
is followed by hypertrophy of the lymphatic glands. The 
lymphatics are, however, usually atrophied in the aged. It is 
impossible to harmonize the generally accepted views concerning 
the functions of the spleen and lymphatics with the conditions 
that exist in the aged. The number and proportion of leuco- 
cytes are not diminished, nor is the character of the blood ma- 
terially altered. Malaria in the aged follows a milder course 
than in maturity and the plasmodium which is believed to be 



SENILE DEGENERATION OF THE DUCTLESS GLANDS 1 29 

destroyed in the spleen, disappears under treatment as rapidly as 
in maturity, though the spleen be extremely atrophied. 

No pathological condition and no disease symptoms can be 
traced to senile degeneration of the spleen. 

Thyroid Gland. — The thyroid gland is atrophied in the aged. 
There is a h^^perplasia of the fibrous structure which compresses 
the alveoli, causing them to atrophy, thereby making the whole 
organ denser. These changes proceed very slowly and the 
organ is normally active to a very old age. There is a vast 
difference of opinion respecting the physiological functions of 
the thyroid in the aged. While PeUiet declares that the thy- 
roid is one of the organs which retains its physiological activity 
longest in senility, Leopold Levi and Lorand ascribe to it 
many or most of the senile changes. Indeed Lorand expresses 
the belief that old age can be deferred by preventing senile 
atrophy of the thyroid or by replacing the waste of the organ. 

According to Horsley, the senile cachexia presents a remark- 
able resemblance to myxedema, which is due to a deficiency of 
thyroid secretion, while those aged persons w^ho do not present 
this cachexia have active, healthy thyroid glands. 

While the thyroid gland has a profound influence upon nu- 
trition and a diminution of its secretion is the cause of cretinism 
and myxedema, it is extremely doubtful whether any of the 
normal senile changes are dependent upon the state of that 
organ. Some of the changes noted in myxedema are seen in 
senility but these are probably incidental to similar degenerative 
results, not causes. 

Edmunds found that if calcium was administered to animals 
in whom the thyroid and parathyroid w^ere excised, the usual 
rapid death following complete thyroidectomy was prevented. 
As there is an increased proportion of lime salts in senility, this 
may explain why functional activity is but slightly disturbed 
in senile atrophy of the gland. Our knowledge of the functions 
of the gland is still imperfect and no definite statements can be 
made as to the character of the functional changes in the aged. 

Suprarenal Glands. — The suprarenal gland is generally atro- 
phied ; Salrazes and Hushot who examined this organ in a num- 
ber of aged persons, found it, however, often hypertrophied. 
There are two antagonistic senile processes, a sclerosis of the 
vessels and an increase in glandular tissue, due to fat deposits 
9 



130 PATHOLOGICAL OLD AGE 

in the cells of the cortical layer. In the lower reticulated layer the 
cells are surcharged with pigment. Contradictory views are 
held concerning the functional changes of the suprarenals, some 
authorities believing that there is a hypersecretion producing or 
aiding in the production of atheroma, high blood pressure, 
pancreatic degeneration, abnormal pigment deposits, etc., others 
denying that the senile organs play any such role in the senile 
processes. Since it is uncertain just what role the senile supra- 
renal glands play in the organism, we cannot say what per- 
version of function or what symptoms are produced. 

SENILE DEGENERATION OF THE SKIN 

The senile changes in the skin have been described in the 
chapter on Anatomical Changes in Old Age. It is, however, 
sometimes impossible to say whether some of these changes are 
physiological or pathological, due to the process of involution, 
to malnutrition following arteriosclerosis, to dyscrasias, to local 
lesions, or are natural and normal conditions under certain 
circumstances not connected with age. Shall we say the weather- 
beaten skin of the sailor is pathological because it is dryer, 
coarser, rougher, more wrinkled and more pigmented than the 
skin of the city dweller, or is it a senile condition because the 
senile exposed skin gradually assumes the same characteristic, or 
is it a normal condition of maturity ? The skin of the aged is dry 
and it is generally possible to rub off fine white scales of dried 
epithelium. Is this pityriasis tabescentium a disease ? Some of 
of the manifestations of senile changes like pruritus, pigmentation, 
etc., are distressing or annoying, while some like bromidrosis may 
exist through life, obvious to everyone except to the individual 
himself. 

There are various perversions of the normal senile changes 
in the skin, some occurring locally, others being scattered all 
over the body. The latter are really dyscrasias or due to 
changes in the blood vessels. (These will be taken up in the 
second group.) Owing to the changes in the skin almost all 
dermatoses occurring in the aged are modified, some presenting 
marked differences between those of maturity and those of 
senility. 

Some of the manifestations of the senile changes in the skin 



SENILE DEGENERATION OF THE SKIN 13I 

are annoying on account of their appearance. Such are folds 
and wrinkles, pigment deposits, the changes in the hair, etc. 
The aged are often more concerned about these than about the 
more important pathological conditions and these are generally 
the most difficult to treat. Pruritus though usually included 
among the diseases of the skin is dealt with under the degenera- 
tion of the nerves as it is probably a symptom of degeneration 
of the nerve terminals. 

Wrinkles are usually the earliest of the senile changes and 
are due to waste of muscular fibers leaving layers of fat. It is 
impossible to replace these fibers and if the fat also wastes the 
skin hangs in folds. Massage will improve the surface circula- 
tion and stimulate the remaining muscular fibers; it might, 
however, cause absorption of the fat and leave the skin in folds. 
This can be avoided by inunction with an animal fat, either 
cream, sweet butter, lard or lanoline, and mild massage. The 
skin should be massaged across the wrinkles, not along the 
wrinkles. 

Florida water, glycerin, bay rum and washes, ointments, 
and other toilet preparations containing alcohol or other desic- 
cants, are harmful. 

Pigment deposits upon the face, neck or hands are unsightly but 
there is no safe and certain method of removing them. There 
are usually extensive areas of pigmentation about the genitals 
and inner surface of the thighs, sometimes upon the chest and 
frequently upon the back and arms. Pigment deposits on the 
face, neck and hand are generally in patches and spots. 
The usual treatment for chloasma patches and freckles applica- 
ble in younger persons will not avail in senility as the drugs 
employed are either irritants or deoxidizing bleaches which act 
as irritants, and owing to poor surface circulation the injury 
done to the skin by them is not readily repaired. Even slight 
surface irritation is liable to cause an ulcer or gangrene. 

The senile skin requires special care to avoid irritation and 
to render it presentable. Soaps containing large amounts of 
alkali or glycerine are injurious, likewise lotions and applica- 
tions containing alcohol. Inunction with animal fats is benefical 
but mineral fat is worthless and may be injurious as it is not 
absorbed and blocks the pores. Face powders and talcum are 
positively injurious. 



132 PATHOLOGICAL OLD AGE 

Senile Alopecia 

Alopecia or baldness is a symptom, not a disease, although 
the pathological condition to which it is due is not always evi- 
dent. There is a primary or idiopathic form including congenital, 
premature and senile alopecia and a secondary form due either 
to a local disease as seborrhea or to a general cause as syphilis. 

Senile alopecia may appear in the fifth decade but is usually 
first noticed about the end of the sixth decade and where there 
has been little falling out of the hair before the senile climac- 
teric it falls out rapidly during or immediatly following this time. 

Pathology. — The corium which forms the walls of the 
hair follicles atrophies and the mouth of the follicle becomes 
filled with epidermal debris. The sebaceous glands atrophy and 
the hair consequently becomes ill-nourished and dry. While 
the follicular walls can still hold the roots in place the dry hair 
becomes thin and breaks at the point of exit from the skin. 
When the follicular walls become so changed that they cannot 
hold the roots the hairs fall out on brushing or combing. 

Symptoms. — In senile alopecia the hair about the central 
point of the scalp back of the crown becomes thin and the hairs 
break off at the point of exit from the scalp. The breaking of 
the hair later occurs all over the scalp, not in patches as in alopecia 
areata, but isolated hairs break everywhere. Owing to the 
atrophy of the corium the roots become loose, fine dust and 
epithelial debris work their way under the roots and push them 
up and brushing or combing dislodges them. The hair falls out 
first about the center of the scalp, the denuded surface gradually 
extending forward, and slowly backward, a thin border of hair 
being left at the sides and back. In some cases the hair first 
breaks over the temples then the rest of the scalp is involved. 

Treatment. — The treatment of senile alopecia has been un- 
satisfactory because the measures employed were based upon 
unscientific empiricisin. Baldness is the end result of many dif- 
ferent conditions and the treatment must consider the primary or 
causative condition. Neglect to discover this underlying cause 
is responsible for the general failure of any certain hne of treat- 
ment which had been successful in a few cases. 

When the hair falls out during a fever it will grow again with- 
out any treatment. If due to parasitic sycosis, treatment insti- 



SENILE DEGENERATION OF THE SKIN 1 33 

tuted before the follicles and roots are destroyed will save the 
roots and the hair will grow ; if the follicles or roots are destroyed 
nothing will avail. In seborrheic dermatitis after the dandruff 
is cured, the growth of hair can be stimulated providing the 
roots and follicles are not destroyed. In senile alopecia the 
success of treatment depends upon the condition of the skin, 
follicles, roots and sebaceous glands. The sebaceous glands 
are generally atrophied but the diminished sebum can be 
replaced by an animal oil or fat. Petrolatum is not an animal 
fat and its employment is harmful. The mouths of the fol- 
licles should be cleaned out by washing the scalp with a 2 per 
cent, solution of biborate of soda. After the head has been 
cleaned a mild stimulant should be used. The best for this pur- 
pose is tincture of cantharides, capsicum or jaborandi, using i 
dram of the tincture to 4 ounces of water. Alcohol, bay rum, 
glycerin and other desiccants which are useful in seborrhea are 
harmful in senile alopecia. The fat or oil should be used only 
after the scalp is thoroughly dried. It may be mentioned here 
that when hair oils, which consisted of animal fats, were used, 
alopecia was far less prevalent than now. 

Hypertrichosis 

Excessive growth of hair or a growth of hair in unusual places 
is a senile phenomenon which cannot be explained by any theory 
of senescence. It occurs most frequently upon the upper lip of 
women, appearing during or soon after the menopause, and in 
the ears, nose and eyebrows of men. The hair is generally of 
the same color as the hair of the head and it retains its color 
long after the earlier hair has turned white. It has no signifi- 
cance and nothing ought to be done to remove the new growth. 
If epilation is desired, the only effective measure is electrolysis. 
This may, however, leave unsightly spots. The ordinary 
depillatories do not destroy the roots and they may produce in- 
flammation and possible ulceration. 

Canites 

Canites or whitening of the hair is a senile manifestation, 
although it appears occasionally as early as the fourth decade. 



134 PATHOLOGICAL OLD AGE 

The cause is unknown. Metchnikoff has shown that chromo- 
phages invade the hair cyHnder and carry off the pigment, but 
in many cases no such organisms can be found. Cases of 
sudden whitening of the hair are occasionally reported and these 
seem to support the theory that the coloring matter can be 
destroyed through nervous influence. It is, however, still un- 
decided if such influence exists or if such reports are warranted 
by facts. Canites generally proceeds slowly and it cannot be 
halted. Nothing has yet been found to take the place of hair 
dyes. 

Changes in the Sudoriparous Glands. 

There is generally atrophy of the glands with diminished se- 
cretion. Occasionally there is excessive secretion in some 
localities as in the axillae, about the genitals and anus, and be- 
tween the toes, and the secretion may have a fetid ordor. Owing 
to impaired sense of smell this odor may not be obvious to the 
patient though it be extremely powerful and disagreeable. 

Treatment. — Amidrosis or deficiency in the secretion of sweat 
rarely requires treatment. Complete suppression occurs only 
in fevers and in nephritis, never as a purely senile condi- 
tion. If a diaphoretic becomes necessary, pilocarpin should not 
be employed. Hyperidrosis, excessive sweating, is seldom so 
marked as to require treatment. It can generally be controlled 
by applying a mixture of equal parts of salicylic acid and zinc 
stearate or one part of tannoform to four parts talcum. Bella- 
donna ointment will suppress the secretion but it may suppress it 
completely and permanently and this may be as undesirable as 
the excessive secretion. If there is intertrigo an ointment of 
zinc oxide 2 drams to vaseline 6 drams should be used and the 
parts separated by a piece of oiled silk. 

Bromidrosis, fetid sweat should be treated like hyperidrosis. 
The surface should be washed with a i to 30 solution of formalde- 
hyde before applying the ointment or dusting powder. 

SENILE MUSCULAR DEGENERATION 

While progressive atonicity and waste of muscular fiber is 
part of the normal process of involution we find occasionly rapid 
or early muscle waste and we may get a pronounced atonicity 
proceeding to complete paralysis. We may find such paralysis 



SENILE MUSCULAR DEGENERATION ^ 135 

due to lessened irritability of the muscle fiber without impair- 
ment of the nerve supply. In muscles that are not much em- 
ployed fatty granules deposit in the connective tissue spaces 
and this fatty infiltration keeps pace with the waste of muscle 
fibers. Fatty degeneration is a pathological process due to some 
disease. The pathological progressive muscular atrophy of the 
young is extremely rare in old age. We find as normal mani- 
festations of senile degeneration of muscle, simple atrophy, 
atrophy with fatty infiltration and functional impairment, di- 
minished strength, slowed and weakened reaction and lessened 
electrical reaction. 

We sometimes find that the functional impairment is greater 
than the atrophy would account for and in these cases there is 
generally fatty infiltration and diminution of nervous irrita- 
bility. This if excessive, forms a distinct disease. 

Progressive muscular enfeeblement of the aged is, accord- 
ing to Oppenheim, due to a multiple neuritis, while Vulpian 
and Donand have shown that there is always a fatty degenera- 
tion of the muscle when this condition exists. 

Etiology. — There is, in addition to the normal enfeeblement 
due to senile waste, some depressive mental or physical influence 
present. It may be the mental depression caused by the reali- 
zation of ageing or it may be shock, fear, prolonged pain, a grave 
disease, neurasthenia, nerve degeneration or insufficient nu- 
trition. 

Pathology. — The muscle is pale, soft, flabby and has a greasy 
feel. The fibers are atrophied, their elasticity is diminished and 
their striations barely distinguishable. There is a deposit of 
fat granules between the fibers. No nerve lesions have been 
demonstrated. 

Symptoms. — There is a general progressive weakness, not 
localized, proceeding more rapidly than the age and the ana- 
tomical changes would justify. Slight exertion causes fatigue 
from which recuperation is slow and not complete. As the 
disease progresses the fatigue becomes permanent, and any 
exertion becomes irksome, finally the patient is too weak to 
arise from bed. There is the will but not the power to move, 
therein differing from neurasthenia in which the will is impaired 
but under some stimulus, the patient will move and act as 
powerfully as in health. 



136 PATHOLOGICAL OLD AGE 

While the disease is strictly confined to the muscles, the 
lack of activity causes involvement of other tissues. Owing to 
lessened activity and the consequent lessened waste, less food is 
required and the diminished metabolic activity causes less heat 
formation. The temperature is consequently lower, the cir- 
culation is slower, aeration proceeds more slowly, gastric diges- 
tion is retarded and there is less elimination of waste. Thus 
various organs and tissues become impaired through lack of 
activity and fatty infiltration results in them. When the 
disease has progressed to such extent that the patient will not 
get out of bed, there is danger of hypostatic congestion followed 
by pulmonary edema, of bed sores and infection, constipation 
with autointoxication or of retention of urine. The feebleness 
may proceed to fatal exhaustion. 

Treatment. — The stimulation of muscle irritability is the 
primary indication. This can sometimes be done by massage, 
coarse vibration or the galvanic current. Where the cause was 
mental depression psychic measures may avail. In some cases 
persuasion, suggestion or harsh measures like threats, a sudden 
scare or disagreeable medication will be effectual. Harsh 
measures should never be employed except as a last resort and 
then only when the physician is certain that the weakness is 
not due to excessive waste or to some pathological condition of 
the structure of the muscle. If drug treatment is required we 
must first determine the condition of the muscles and nerves. 
Where there is marked fatty infiltration, the iodides are required. 
They favor destructive metabolism and if combined with passive 
exercise they will bring about waste of fat. At the same time 
strychnine, phosphorus, small quantities of alcohol and other 
nerve stimulants should be used and if the hemoglobin per- 
centage is reduced, hemoglobin should be added. 

Localized muscle weakness if not due to traumatism is 
almost always due to degeneration of the nerve supplying the 
part. 

SENILE ARTHRO SCLEROSIS 

This disease, first described under the term senile rheuma- 
tism, is a hardening and stiffening of the joints due to the senile 
changes in the tissues forming the joint. 

Pathology. — The tendons are hardened, there is ossification 



SENILE ARTHROSCLEROSIS I37 

and sometimes calcification of cartilages, the cartilages covering 
the articular surfaces waste through attrition and fibrillation, 
the ligaments harden and shorten and the synovial sacs become 
dry. 

Sjonptoms. — The joint gradually becomes stiff but there is 
never complete anchylosis. The joint is not swollen, reddened 
or inflamed. There is no pain when it is at rest but there is 
an ache upon motion, the pain and stiffness increasing with in- 
creasing or prolonged motion. Sudden severe motion produces 
a severe pain. As the patient becomes weaker motion becomes 
more irksome owing to the increasing stiffness of the joints. 

Diagnosis. — Arthrosclerosis senilis is frequently mistaken 
for chronic rheumatism. There is no history of rheumatic fever, 
the pains do not get worse at night, there is no pain when the 
body is at rest and there are no paroxysmal attacks of pain. 
The pain and stiffness of chronic rheumatism is lessened upon 
motion or upon ''limbering up," as the patient calls it. 

Owing to the difficulty in arising from a sitting position, 
this disease is often diagnosed as lumbago or myalgia. In the 
senile condition there is hardening and stiffening of the vertebral 
joints with waste of the muscles of the back, but no myositis. 
The ache becomes progressively more severe but there is no 
pain when the patient is at rest or turns in bed. In myalgia 
the pain comes on suddenly, is generally severe, at times 
paroxysmal with painless remissions, while in lumbar myalgia, 
turning in bed is painful. 

Treatment. — While the salicylates and local counterirritants 
are of benefit in the rheumatic conditions they are absolutely 
useless in the senile condition. The treatment in these cases 
is purely empirical; in some cases psychic methods in some 
hydrotherapy, in some drug treatment, is effective. Hot 
baths or hot appHcations over the joints followed by inunction 
with an animal oil or fat is often beneficial. In some cases 
the best results are obtained from mild or coarse massage or 
vibratory treatment. The internal medication must be directed 
to overcome the senile debiHty, phosphorus, arsenic, strychnine, 
hemoglobin, etc. Occasionally psychic influences are more 
effective than drugs and among such influences must be in- 
cluded the empirical use of liniments which the patients them- 
selves employ. The local use of alcohol is contraindicated. 



138 PATHOLOGICAL OLD AGE 

PSEUDO-PAGET'S DISEASE 

This name is a misnomer, the disease being a rare form of 
osteoporosis occurring in old age. The head is held forward, 
the knees are slightly flexed, and the legs are spread apart. 
The hands are held out from the body, there are deformities 
in the lower limbs and trunk, the angle of Louis in the sternum 
is prominent, and the whole thorax seems to be pushed down 
into the abdomen. The latter shows a rounded eminence in 
the epigastrium and hypogastrium, deep transverse folds above 
the umbilicus ending laterally in depressions in the hypo- 
chondriac area, and a diminution or obliteration of the space 
between the ribs and the crest of the ilium. The spinal column 
shows one curve with the convexity posteriorly. When the 
heels are held together the internal condyles of the femurs are 
far apart. The general appearance is that of Paget's disease 
but it occurs much later in life, generally in the eighth decade. 
It is apparently an extreme type of senile degeneration of the 
bones and a disease to the extent of producing discomfort and 
deformities. There is no treatment, but braces and a cane can 
retard the changes and prevent the stoop. 

SENILE DEGENERATION OF THE BRAIN 

Senile Dementia 

The ordinary senile changes in the brain have been described 
in the chapters on Anatomy and Physiology. In many cases 
more profound histological and physiological changes occur and 
give rise to symptoms for the relief of which medical care is 
indicated. We must remember, however, that there is but little 
releotionship between the organic and the functional changes, 
that mentality depends upon some unknown quality of the 
brain cells and not upon size of brain or amount of brain sub- 
stance, that brain substance has been lost without alteration of 
mentality or sensory-motor impairment. Memory is most 
active during the period of development, while reason and 
judgment increase for years after the brain has reached the 
limit of growth and even while it is in the process of atrophy. 
In some the comparative and constructive faculties remain 
unimpaired to the end of life while the conservative fa- 





Pseudo-paget's Disease. Xouvelle Iconographie de la Salpetriere, 
Jan.-Feb., 1905. 



SENILE DEGENERATION OF THE BRAIN 1 39 

culty shows diminished power even before the completion of 
development. 

Etiology. — The diminution in the weight of the brain begins 
normally about the end of the fourth decade of life, soon after 
it has reached its greatest weight and years before the atrophy 
could reasonably be charged to diminished nutrition from 
cerebral arteriosclerosis. The causes that prevail in old age, 
such as impaired nutrition and neurophages, do not prevail 
when the atrophic changes begin and no theory has been ad- 
vanced to explain it. As most of the psychic and somatic 
functions increase for a time after the brain begins to atrophy, 
it is reasonable to assume that the waste begins in those cells 
controlling the functions that are lessened about this time. 
In what portion of the brain these cells are located is unknown. 

We find that organs and tissues which have been insufficiently 
employed and those which have been used excessively break 
down early. Activity demands increased blood supply to re- 
pair waste, and inactivity lessens the circulation in the part. 
Prolonged inactivity causes a lessened supply of blood and a 
slowed circulation with the inevitable result of deficient nutri- 
tion and waste of tissue. Excessive activity hastens degenera- 
tion partly through fatigue toxins, partly through incomplete 
repair. There may be also a hastening in the evolution of 
tissue cells, causing a more rapid development of the cells of 
an advanced evolutionary stage. 

The same causes may apply to the brain cells. Persons of 
low mentality, such as the uneducated peasants, find it almost 
impossible to learn anything new after their thirtieth or thirty- 
fifth year. They may retain the memory of events that have 
made a powerful impression upon them but they cannot learn 
a new language, though spending years among those who 
speak that language. In these persons the cells involved in 
memory become functionless from disuse and if the same process 
goes on in them that goes on in functionless cells of other tissues 
they waste. If on the other hand the conservative faculty has 
been excessively employed, a rapid deterioration will occur when 
the functional capacity of the cells has been exceeded. As the 
mentality differs in different individuals, the functional capacity 
differs. One child will get brain fag from studying the same 
lesson that another child of the same age acquires without 



I40 PATHOLOGICAL OLD AGE 

difficulty. The enormous amount of information acquired by 
the child can be gleaned by comparing the school curriculums, 
age for age, of today with the curriculums of forty years ago. 
The increase represents only the additional information ac- 
quired since that time. The result is that the conservative 
faculty is excessively employed and by the time that brain 
development is complete and other faculties are fully active, 
this faculty begins to become impaired and it is probable that 
the cells engaged begin to degenerate. 

When the circulatory changes of advancing age are active 
and the nutrition of the brain is impaired, the cell degeneration 
proceeds more rapidly, reason and judgment become impaired, 
and at the same time the somatic functions become weakened. 
Metchnikoff has shown the influence of neurophages upon brain 
cells but it is not at all certain that these phagocytes appear 
in every senile case. When they are present they are a potent 
factor in causing tissue waste. 

Pathology. — There are marked changes in the brain tissue and 
in the vessels. The changes in the latter have been described 
under Arteriosclerosis. The extent of the arterial degeneration 
varies, in some cases only the small vessels and capillaries being 
involved, in others the large vessels alone or the whole arterial 
system of the brain is affected. Miliary aneurysms are frequent. 
The changes are fairly uniform in character but differ in degree. 
When they are far advanced the weight of the brain may be 200 
grams below the weight of maturity, the waste being principally 
in the frontal lobes, the cerebrospinal fluid is increased, the pia 
mater is thickened over the entire cortex, contains amyloid bodies 
and plaques of calcareous matter, the dura adheres to the bone 
and there may be a pachymeningitis interna. The convolutions 
may be edematous, the sulci are shallow, gaping and filled with 
adventitious pia. Minute hemorrhages are often found in the 
cortex and basal ganglion which form the foci for softening. The 
spongy sieve-like appearance described as Etat-Crible is present. 
The ventricles are dilated and the ependymal wall is thickened. 
There is a hypertrophy of the neuroglia, and atrophy of the cor- 
tical neurones. The cell bodies become shrunken and diminished 
in number and the processes become tortuous, narrow and short. 
The physiological increase in yellow pigment in the cells may 
proceed to pigmentary degeneration. The changes here de- 



SENILE DEGENERATION OF THE BRAIN I4I 

scribed are present in advanced cerebral degeneration such as is 
usually found in senile dementia. 

Symptoms. — The functional changes in the senile brain 
include mental deterioration and physical impairment. In 
determining the extent of senile impairment, the normal men- 
tality of the individual should be known. The impairment, 
though manifested in many directions, may progress for years 
before it becomes obvious to friends and the family who con- 
stantly surround him. An early symptom of the deterioration 
is a hesitancy in recalling nam^es, dates and events, fabricating 
others if the patient thinks the fabrication will not be discovered. 
The fictitious name, date or event will probably be forgotten 
the next day and if the right answer is not recalled the new 
name, date or event will also be forgotten and another substi- 
tuted. The patient will forget where he puts things, will repeat 
questions that had just been answered, forget the names of 
persons to whom he had just been introduced, and if interrupted 
while speaking he will forget where he left off or he may forget 
the subject altogether. Attention is defective and prolonged 
effort to maintain attention leads to brain fag. The aged person 
who falls asleep during the play or sermon does so through 
excessive attention with consequent brain fag and not through 
inattention or indifference. He must make a sensible effort to 
understand the connection between things where such connections 
ought to be instantly obvious. He becomes careless about 
details and loses the sense of neatness, leaving his desk disordered 
his room untidy, his clothes disarranged. Business and social 
affairs are not clearly comprehended and this gives rise to errors. 
Errors in playing cards, usually charged to inattention, errors 
in calculation, charged to carelessness, slips of the tongue, 
absent-mindedness, etc., are due to inability to concentrate 
attention to one object. He becomes egotistic, exaggerates 
his own importance and his interests, becomes sensitive to what 
he considers to be neglect of himself or his interests and thus 
dislike, hatred, fear and finally oikiomania are developed. This 
may proceed to delusions of persecution. 

There is generally a pronounced change in temperament 
and emotional attitude. There is frequently depression due 
either to the recognition of waning powers and the nearness of 
the closing period of life, or to fancied neglect. The patient 



142 PATHOLOGICAL OLD AGE 

becomes peevish and irritable and will exhibit anger upon the 
slightest provocation. Elation is rare. His self-interest de- 
stroys interest in others and while he may show external sym- 
pathy by weeping there is rarely profound grief or joy and these 
are soon forgotten. The aged take frequent naps during the 
day, as mental and physical fatigue set in quickly upon activity, 
and at night they are often restless and walk about aimlessly 
or they will repeatedly try doors and windows, search through 
closets, desks, trunks, etc., without any object. Inability to 
accommodate himself to a progressive order of things is a fre- 
quent accompaniment of old age. While there is general mental 
decadence, in some cases the reasoning faculties are not im- 
paired and where the mental efforts are all directed into one 
channel, remarkable work may be done in this one direction, 
but in other directions the impairment is more pronounced. 
What are usually looked upon as whims, hobbies and peculiari- 
ties of great men of advanced age are really manifestations of 
mental impairment. A deeper grade of mental impairment 
often seen in the senile climacteric is senile confusion. This 
condition is marked by disorientation. The patient walks 
aimlessly and unconsciously, oblivious of his surroundings and 
often in dangerous localities; and if he can be roused, mental 
clearness is awakened but almost immeditely dissipated. He 
loses track of time, distance and direction, goes out in winter 
without a coat, may undress in the street, speak to strangers, 
especially to children, talking senseless drivel. Memory may 
be so weakened that he forgets his own name and if spoken to 
he shows by his answers that he cannot comprehend or com- 
prehends but imperfectly the import of the question. He 
is garrulous but there is incoherence of thought with gradually 
deepening impairment of comprehension until the condition 
of complete dementia is reached. In this condition the indi- 
vidual resembles either the absolute idiot who had never had 
a trace of intelligence and is consequently quiet, or — as in 
terminal dementia — is moving automatically, mumbling, with 
occasional outbursts of silly laughter, shrieks, etc. 

Senile delirium occurs occasionally during the senile climac- 
teric. It is marked by hallucinations and great activity. 
There are usually the symptoms of senile confusion with short 
attacks of delirium during which there are delusions and hallu- 



SENILE DEGENERATION OF THE BRAIN I43 

cinations that are forgotten when the remission occurs. In 
some cases the attacks come on suddenly; the patient sitting or 
walking quietly begins to shout or sing, walks rapidly up and 
down the room, seeing things or hearing strange sounds. In 
other cases the attack comes on gradually with restlessness and 
increasing activity. Prostration may occur, but usually the 
attack subsides gradually until the patient is quiet. On rare 
occasions the mind clears up for a short time. 

Senile dementia in its medicolegal relations will be treated 
under that chapter. 

The somatic derangements due to cerebral degeneration 
have not been clearly defined. Impaired coordination is 
generally of cerebral origin and senile tremor, the increasing 
physical weakness, paraplegia and diverse impairments of the 
senses and sensation may be due wholly or partly to cerebral 
degeneration. Impairment of sensation and of the special 
senses is often due to a weakened mind, which does not readily 
interpret the impressions received. We sometimes find that 
under an extraordinary mental stimulus, as the fear of death in 
a burning building, the mind clears up, the senses become 
normal and even strength may be temporarily restored. In 
such cases the effort is but momentary and is followed by pro- 
found reaction. 

Treatment. — True senile dementia is progressive and incur- 
able, but much can be done in the early stages of mental dete- 
rioration to impede its progress, and in advanced stages it is 
sometimes possible to temporarily rouse the individual to a 
comprehension of his surroundings and his condition. 

The keynote of treatment is mental stimulation. This is 
opposed to the usual treatment of this condition by rest and 
quiet. Unless it is a terminal dementia which requires the 
constant presence of an attendant and mentality is so far gone 
that no impression can be made upon it, the patient should not 
be placed among insane patients nor immured in an asylum. 
Our object should be to rouse the patient to take an interest in 
something else than in his body and his fate. His mental facul- 
ties should be constantly employed until brain fag sets in, but 
mental confusion should be avoided. To give a homely illus- 
tration, he may watch a one-ring circus until after a time brain 
fag will set in and he will fall asleep. If he tries to watch a 



144 PATHOLOGICAL OLD AGE 

three-ring circus there will be mental confusion, possibly delu- 
sions, and insomnia. Pleasurable sensations should be pro- 
duced, especially such as the patient is familiar with. An old 
popular song will often rouse an aged person out of lethargy, 
and this is one of the most effectual means to bring about a 
temporary clearing of the intellect. The concert, ballet or what- 
ever else will produce harmony of color, sound or motion will be 
beneficial. The monotonous routine of the asylum hastens 
dulling of the intellect and the association with insane will rouse 
delusions. As the deterioration increases a constant change of 
environment, of sight, scenes and sounds is necessary. If there 
is mental confusion it will be necessary to place the patient in a 
position where the attention can be concentrated upon one 
object alone, a view of the sea or distant mountains, a familiar 
song, or poem, a favorite child or grandchild, etc., changing the 
object from time to time but always selecting an object pleasing 
to the patient. In the apathetic and melancholic forms of 
dementia it may be advisable occasionally to subject the patient 
to excitement such as a lively seaside resort a masque ball or 
carnival and though this will produce mental confusion it will 
stimulate mental activity. The most powerful psychic impres- 
sions are often produced by the flattery of young persons of the 
opposite sex and there is probably nothing that will so effec- 
tually produce mental and physical rejuvenescence as a young 
husband or wife. A recrudescence of sexual desire in the aged 
without psychic causes, as pornographs, erotic literature, con- 
versation or suggestion, is a symptom of senile dementia. When, 
however, such desire can be stimulated by psychic measures 
it indicates a state of mind susceptible to improvement. We 
can thus explain the remarkable mental and physical improve- 
ment in aged men who marry young women. 

Of drugs, phosphorus and morphine are the best mental 
stimulants. Morphine in small doses produces a mental stimu- 
lation which passes off in a few minutes or hours. Habituation 
is, however, rapidly induced and if frequently repeated the 
stimulating effect is diminished and finally lost unless the dose 
is constantly increased. If this is persisted in, death will result 
from morphine poisoning. Morphine in i/20-grain dose may 
be used occasionally if temporary mental stimulation is desired. 
Small doses of cannabis indica will stimulate the imagination, 



SENILE DEGENERATION OF THE CORD I45 

generally, however, in the direction of delusions and illusions. 
Alcohol is worse than useless. Phosphorus is the best mental 
and nervous stimulant we have as it is positive in action and 
there is no habituation. It should be given when the first 
symptoms of mental deterioration appear, discontinued when 
there is a response in a brighter mental attitude and resumed 
when this passes away. The dose of the ordinary phosphorus 
is i/ioo grain gradually increased to 1/20 grain, always in 
solution. For several years the author has used amorphous 
(red) phosphorus in doses of i grain gradually increasing to 5 
grains three times a day. 

SENILE DEGENERATION OF THE CORD 

Senile degeneration of the cord gives rise to numerous func- 
tional disturbances. It is, however, often impossible to deter- 
mine the relation between the structural changes and the fimc- 
tional impairment, as similar histological changes may present 
the most diverse symptoms, while similar symptoms may be 
associated with different forms of degeneration or in different 
locations. Sometimes profound functional impairment exists 
yet no degenerative change is found after death and extensive 
areas of degeneration have been found upon autopsy which gave 
no symptoms during life. Extensive atrophy of the cells of the 
anterior horns has been found in cases which gave no symptom 
of progressive muscular atrophy and scattered areas of sclerosis 
are often found upon autopsy of very old persons, who did not 
present the symptoms of multiple sclerosis during life. In 
some cases degenerative changes will be found without symp- 
toms but with a history of earlier nervous disease which has 
been cured. 

The typical senile degeneration of the cord is seldom found 
before the seventh decade, but the early manifestations of 
spinal impairment, weakened and slowed impulses and tardy 
response to impulses, are observed in the sixth decade. Dimin- 
ished irritability and impairment of the muscle sense are noted 
about the same time, weakened coordination and lessened 
muscular power appear later and still later senile tremor makes 
its appearance. There is an increasing weakness in the lower 

limbs which in extreme cases may become a paraplegia, but 
10 



146 PATHOLOGICAL OLD AGE 

senile paraplegia is never complete. In some cases the loca- 
tion of the degeneration and the functional impairment do not 
correspond and we may have a degeneration of the upper part 
of the cord with no other symptom than paraplegia. In most 
cases, however, the impairment corresponds with the degenera- 
tion of that part of the cord which supplied the impaired tissue. 
The progressive weakness of the aged is caused partly by the 
waste of muscle and partly by cord and nerve weakness, and 
exaggerated by the mental condition of the individual. (The 
weakness of the cord which is due to its degeneration will be 
described in the following chapter under the head Senile De- 
generative Myelitis.) 

SENILE DEGENERATIVE MYELITIS 

This term is applied to senile degeneration of the cord when 
its manifestations are pronounced enough to produce distressing 
symptoms or profound functional impairment. It is not an 
inflammatory process. 

Pathology. — There is usually atrophy of the ganglionic 
cells, with increase of cerebrospinal fluid, the cord as a whole 
is firm but there may be spots or patches of sclerosed tissue and 
occasionally areas of softening are found. The motor areas are 
usually first affected. 

Symptoms. — There is no uniformity in the symptoms or 
regularity in the order of their appearance. The one symptom 
present in all cases is a gradual weakening of the lower limbs, 
the so-called senile paraplegia. If the cervical portion of the 
cord is affected there is motor paraplegia, degeneration of the 
dorsal portion produces a spastic paraplegia, and if situated in 
the lumbar portion there is motor and sensory paraplegia. In 
, degeneration of the lumbar portion the reflexes are diminished; 
if there is dorsal degeneration, they are increased. In many 
cases areas of degeneration are scattered throughout the entire 
cord and we may then find exaggerated or diminished reflexes, 
even an increased knee reflex while the tendon Achilles reflex is 
diminished or vice versa. The paraplegia comes on slowly, is 
progressive and never becomes complete. The sphincters are 
rarely involved except when due to local causes. Senile para- 
plegia is generally associated with senile abasia and sometimes 
with senile tremor. 



SENILE DEGENERATIVE MYELITIS 1 47 

Senile abasia is the slow unsteady gait of the aged when 
walking without a cane and is due to lessened coordination, 
muscular weakness, bent knees and the fear of falling. This 
fear is aroused through the greater difficulty in maintaining 
equilibrium which now requires a conscious effort. Occasion- 
ally there is a slow, tremulous tripping gait, the ''abasia trepi- 
dante" of Petrens, and when this is associated with senile 
tremor and senile paraplegia we get a clinical picture resembling 
paralysis agitans. (For diagnosis see Senile Tremor.) 

If the paraplegia is of cerebral origin there is instability on 
turning around. There is also mental impairment more pro- 
nounced than the usual impairment at the patient's age. A 
myopathic form of senile paraplegia originates in the nerves of 
the muscles and produces cramps and contractions and later on 
atrophy. In the spinal form there is no atrophy except the 
usual waste due to age and disuse. 

The treatment of senile abasia is mainly psychic. It is 
necessary to overcome the fear of falling and to do this we must 
improve the sense of well-being of the individual. A cane is 
necessary and it should be so long that the patient need not 
bend over to grasp the handle when the point on the ground is 
at the distance of an ordinary step from the body. The me- 
dicinal treatment is the same as has been given under senile 
cachexia. Rubber-heeled shoes should be used and ankle 
supports and arch supporters should be fixed in the shoes even 
if local conditions do not make them necessary. The sense of 
security derived from their use will often overcome the fear of 
falling and will enable the patient to make a firmer step. 

A form of senile paraplegia which Demange calls ''Contrac- 
ture tabetique progressive des atheromateux,'' is characterized by 
a progressive contraction of the muscles of the lower extremities 
with increased tendon reflex. He ascribes the disease to a 
degeneration of the lateral fibers following atheroma of the 
smaller branches of the spinal artery. The symptoms have 
been found without the anatomical changes and the anatomical 
changes have been found without the symptoms. Sensory im- 
pairment is frequently found in the aged but it is often impos- 
sible to say if it is due to the brain, cord, nerves or end organs. 

Treatment. — As it is generally impossible to localize senile 
degenerations of the cord, treatment must be applied through- 



148 PATHOLOGICAL OLD AGE 

out its length. The most effective method of stimulating 
spinal activity is by the application of the faradic current after 
moist heat had been applied. It is impossible to restore de- 
generate tissue but it is often possible to stimulate functional 
activity where it is lessened and that is, after all, the aim of the 
physician in treating senile cases. 

Internal medication is limited to phosphorus, arsenic and 
strychnine. If there is a luetic taint the iodide of arsenic should 
be used. The precautions concerning these drugs, given in 
the treatment of senile cachexia, must be observed. Strychnine 
is the most powerful of the spinal stimulants, but it must be 
given in constantly increasing doses and we have no means of 
overcoming its excessive stimulation of the heart. That organ 
must be watched when giving strychnine. Palpitation or 
increased blood pressure is the indication to stop its use. Cold 
sponges are harmful. Occasionally some intense psychic im- 
pression will temporarily restore the power and sensibility of 
the limbs. 

SENILE TREMOR 

This is a neurosis for which no pathological lesion has been 
found, nor is there much known concerning its etiology. Pic 
says it is a manifestation of an irritable enfeeblement of the 
nervous system of the neuropath. In most cases there is a 
neurotic taint, occasionally hereditary; more often there is a 
history of antecedent nervous disease. (It is placed in the 
first group on the assumption that it is a manifestation of 
general debility and a symptom of advanced senile degenera- 
tion of the cerebrospinal system.) Some cases are traceable 
to suggestion or mimicry. 

Symptoms. — Senile tremor generally begins with an unsteadi- 
ness of the hand which has done the most work, then both 
hands are affected and slight muscular exertion causes them to 
tremble. Later the head and neck muscles are involved. The 
lower limbs are rarely affected except after considerable exer- 
cise, such as a long walk, taking long steps, climbing stairs or 
swinging the legs when bent at the knee. It is a slow inten- 
tion tremor, the oscillations not exceeding five per second, and 
coming on only during the voluntary contraction of the muscles. 
The tremor is most noticeable in the head and neck muscles, 



SENILE TREMOR 1 49 

there being a coarse tremor of the head, a fine tremor of the Hps, 
and a shaking or trembling of the lower jaw. The shaking of 
the head is generally in an up and down (vertical) direction 
but a tremor in a horizontal direction and even a rotary motion 
have been observed. The tremor of the lower jaw resembles 
the motion of mumbling, occasionally that of chewing. 

The tremor is increased upon excitement or exertion but 
may be temporarily controlled by the will. In some cases the 
tremor is confined to the hands during voluntary motion. 

The head does not tremble when supported by the hand 
and the tremor ceases during sleep. 

Diagnosis. — Senile tremor is diagnosed from paralysis agi- 
tans by the absence of the characteristic attitude, gait, muscle 
stiffness, cramps, forward pitch, posture of the hands and the 
immobile facial expression of the latter disease. If senile tremor 
is associated with abasia trepidante, there may be a similar 
gait and a tendency to pitch forward, but the other symptoms 
of paralysis agitans are absent. The tremor of the hands in 
senile tremor resembles the tremor of disseminated sclerosis 
but the latter is a disease of early and middle life, and is charac- 
terized by a spastic gait, a rapidly increasing weakness, nystag- 
mus with other ocular symptoms, and peculiar scanning 
speech, all of which are absent in senile tremor. The toxic 
tremors, as from alcohol, tobacco, lead, mercury, etc., are inten- 
tion tremors but the history and accompanying symptoms 
readily distinguish them from senile tremor. In hysterical 
tremor other symptoms of hysteria and the absence of tremor 
when the attention is diverted, determine the diagnosis. 

Treatment. — Drugs useful in other tremors have no effect 
upon senile tremor. Neither hyoscine, hyoscyamine, duboisine, 
the bromides nor iodides are of any use. The only drugs which 
seem to have any effect are arsenic and strychnine in gradually 
increased doses to the limit of tolerance of the former and until 
palpitation of the heart indicates that the strychinne is acting 
unfavorably upon that organ. Psychic measures, especially 
flattery, will sometimes cause arrest of the tremors by concen- 
trating attention to them and rousing a persistent effort to 
control them. If the tremor is due to imitation, harsh meas- 
ures, such as threats, deprivation of food, etc., may be necessary 
to effect a cure. 



150 PATHOLOGICAL OLD AGE 

SENILE DEGENERATION OF THE NERVES AND 
END ORGANS 

Pathology. — The degenerative changes in the nerves are a 
hyperplasia of the neuroglia and an atrophy of the nerve cells 
and fibrils, more marked in the terminal fibers and diminishing 
toward the center. The senile changes in the nerves appear 
late in life, indeed in many cases no histological changes can be 
found to account for symptoms evidently due to the nerves. 
It is often impossible to say whether a neuralgia, local paralysis, 
motor or sensory impairment, tremor or reflex perversion is 
due to cerebral, spinal, nerve or end organ defect. In some 
cases giving the symptoms of neuritis we can find the patho- 
logical changes observed in chronic interstitial, parenchymatous 
or multiple neuritis but in most of these cases we can discover 
an etiological factor besides senile involution. 

Symptoms. — The functional activity of the nerves is dim- 
inished, motor impulses are slowed and weakened, sensibility is 
lessened, the special senses are impaired and the functions of the 
regulation centers are slowed, weakened and sometimes per- 
verted. The loss of muscular strength is due partly to the nerve 
changes and partly to waste of muscle and lessened muscle irri- 
tability. The impairment of the special senses may be due to 
degeneration of the afferent nerves or it may be due to some 
change in the end organs or in the brain. It is probable that 
the nerves and end organs are both involved while the brain is 
less able to receive and interpret sensory impressions. Fear 
exaggerates the sensation of pain and the aged complain of 
acute pains where the local condition does not give rise to much 
pain. The patient may complain of intense pain from a scratch 
which he can see, yet he will hardly notice the pain from a peri- 
tonitis, pleurisy or acute gout when he cannot see the diseased 
tissue. Suggestion and mimicry will give rise to painful sensa- 
tions without any lesion of the part or of the nerve supplying it. 
It is important in examining a patient for painful spots that no 
hint be given of the object of the examination, lest the patient 
should declare that any spot is painful over which greater pres- 
sure is made or to which his attention is directed. 

Little can be said of the regulation centers. The heat 
regulation, cardiac regulation, vasomotor centers, etc., are all 



SENILE DEGENERATION OF THE NERVES 151 

impaired but they have not been sufficiently studied to make 
definite statements about them. 

The optic nerve and retina are rarely affected but there may 
be a degenerative albuminuric retinitis associated with a gener- 
alized arteriosclerosis and chronic interstitial nephritis. Optic 
neuritis or choked disc is occasionally found under the same 
circumstances. The motor nerves of the eyeball show neither 
histological nor functional changes. There is often a slowness 
of action of the motor muscles which may be due to muscle 
weakness or to slowed mental impulse or response. The termi- 
nal ends of the third branch of the trifacial nerve are some- 
times subjected to pressure in the bony structure of the lower 
maxilla and this gives rise to trifacial neuralgia (see Trifacial 
Neuralgia). It is supposed that neuralgia of the second branch 
is due to arteriosclerosis and consequent impaired nutrition, 
although this form of neuralgia often appears with no demon- 
strable lesion in either nerve or blood-vessels. The lingual 
branch shows frequently functional impairment in diminished 
taste without histological change. 

The facial nerve is rarely if ever affected as the direct result 
of senile changes. When facial paralysis occurs, it either 
follows cerebral disease, or a neuritis, or it is due to exposure, 
traumatism, pressure or other cause not connected with the 
senile processes. 

The glossopharyngeal nerve shows in the aged frequent func- 
tional impairment in diminished taste. It is, however, uncer- 
tain to what extent degeneration of the taste buds contribute 
to this result. The dysphagia of the aged is due to lessened 
innervation of the muscles of deglutition. Various functional 
perversions in parts supplied by the vagus are believed to be due 
to senile degeneration of that nerve. To this cause are ascribed 
the anomalies in the rhythm of the heart and of respiration, 
pharyngeal and laryngeal spasm, aphonia, and most gastric 
neuroses. 

The spinal accessory nerve shows no marked functional 
change in old age. It is probable that the weakening of the 
sternomastoid and trapezii is due to weakened power of this 
nerve, but the weakness of these muscles is rarely more marked 
than in other voluntary muscles. 



152 PATHOLOGICAL OLD AGE 

The hypoglossal nerve presents no symptoms that can be 
ascribed to senile degeneration. 



Senile Degeneration of the Organs of Special Sense 

The special senses are weakened or perverted in old age but 
we can rarely tell with any degree of certainty whether the 
fault lies in the terminals, nerves or cerebral centers, nor whether 
the cause is senile involution or something else. In many cases 
no histological changes can be found. 

Anosmia, loss of smell, may be due to obstruction of the 
passage of air to the Schneiderian membrane, to atrophy or 
degeneration of this membrane or of the olfactory nerve or 
bulb, or there may be a senile dementia with diminished power 
to receive or interpret sensory impressions, or it may follow 
other nasal diseases or hysteria. The loss of smell may be con- 
fined to certain odors or it may be more marked at certain times, 
as in damp weather. The sense of smell is usually the first of 
the special senses to show diminution of power, the impairment, 
however, is rarely noticed and complete anosmia may exist 
without the knowledge of the individual. 

Parosmia or a perverted sense of smell may be due to the 
same causes as anosmia, the perversion preceding the latter, 
cr it may be due to mental aberration, hysteria or neurasthenia 
or to oral or nasal disease producing a fetid odor. It is often 
an early symptom of insanity. 

If the anosmia is due to senile degeneration nothing can be 
done to increase the sense of smell. The treatment of parosmia 
is either local or psychic depending upon the cause. 

Gustatory anesthesia generally accompanies anosmia but it 
rarely proceeds to the same extent. Taste may be lost for 
certain substances, or only the temperature sense may be af- 
fected. There is usually a blunting of the sense of taste for 
alkaline, sweet, insipid and bitter substances but not for salty, 
acid or acrid ones. The impairment may be due to a change 
in the taste corpuscles, in the nerves of taste or in the cerebral 
centers. Probably all three are responsible for the functional 
impairment, the papillae being mainly affected through the 
changes in the covering membrane of the mouth and the changes 
in the oral secretions. 



ENILE DEGENERATION OE ORGANS OE SPECLA.L SENSE 1 53 

Gustatory paresthesia is rare except in insanity or hysteria. 
Nothing can be done to increase the sense of taste due to senile 
degeneration. 

Preshyacusia, diminished sense of hearing, due to age is fre- 
quent and often proceeds to complete deafness. The apprecia- 
tion of high notes is generally lost and low notes appear higher. 
Tinnitus and other abnormal soimds indicate a pathological 
condition ; they do not appear in the ordinary senile impairment 
of hearing. They are generally associated with cerebral or 
local arteriosclerosis. Presbyacusia occurs earher in the cities 
than in the country and w^hen found in city dwellers it proceeds 
more rapidly and is more frequently subject to compHcations 
which convert the normal process into a disease. The char- 
acter of the senile process is unknown as both atrophy and 
thickening of the drum have been foimd in the aged, with vari- 
ous degrees of deafness and without functional impairment, 
while complete deafness may exist without drum or nerve 
change, or any other known cause. It is believed that many 
cases of senile deafness are of cerebral origin. 

Presbyacusia is sometimes overcome by the use of a speak- 
ing tube, mechanical drum or other apphance which will cause 
more direct conduction or intensify the sound. Drugs and 
operative procedure are useless. 

Presbyopia or difficulty in accommodation to near objects 
is the ordinary condition of the senile eye and is due to sclerosis 
of the lens with probable weakening of the muscles of accommo- 
dation. The contracted pupils and slowed reflexes are prob- 
ably due to changes in the nervous supply and in the muscles. 
No distinctively senile changes have been found in the retina 
or optic nerve and in those who have not abused their eyes the 
sense of sight remains normally acute. Presbyopia like presby- 
acusia occurs earlier in the cities, it proceeds faster and com- 
plications are more frequent. Amblyopia is frequently found 
in the aged; it is, however, not a senile condition. The treat- 
ment for presbyopia is appropriate glasses. Perversions of 
sight and hearing that are not insane illusions may occur in 
cerebral and auditory arteriosclerosis but they do not occur in 
the ordinary senile degenerations of the organs. 

Anesthesia is frequently met with in the aged. It is usually 
partial, there being a weakened perception of touch, pain and 



154 PATHOLOGICAL OLD AGE 

temperature. Complete loss of sensibility occurs only in some 
forms of spinal degeneration and is then associated with motor 
paralysis. No senile anatomical change of a degenerative 
character has been demonstrated in the tactile organs and it is 
uncertain whether the functional impairment is due to slowed 
conduction, weakened cerebration or to some morphological 
change which has hitherto defied recognition. 

Hyperesthesia is rare in old age, and the excessive sensitive- 
ness from which the aged often complain is generally exaggerated 
through the fear of pain. 

Paresthesia occurs frequently in the form of pruritus and 
eccasionally as formication. 

Senile Pruritus 

Etiology. — This is one of the most frequent and most annoy- 
ing of the ailments of old age. It is sometimes due to psychic 
causes, either suggestion or mimicry. Epidemic senile pruritus 
in institutions has been traced to mimicry, one patient suffering 
from a pruritic affection and others seeing that patient scratch, 
do likewise. The mere mention of an itch-producing cause, 
such as fleas, will sometimes suffice to arouse the sensation of 
itching. If we can exclude these psychic causes as well as 
the pruritic dermatoses presenting surface lesions, parasites, 
also the diseases which are usually accompanied by pruritus, 
such as diabetes, jaundice, leukemia, pseudoleukemia and neph- 
ritis, and finally all local causes of irritation, such as woolen 
underwear, acrid bromidrosis, etc, we necessarily deal then 
with the true senile pruritus of unknown etiology and no dis- 
coverable pathology. Lesions may appear, due to scratching, 
but no change has been found in the end organs to account for 
the pruritus itself. 

Symptoms. — The itching may be protracted, intermittent 
or ephemeral, so mild as to be barely noticed or so severe as to 
cause intolerable agony, it may be generalized, scattered over 
large or small areas or localized. When localized it is generally 
found about the genitals and anus, sometimes about the legs, 
rarely in other locations. The itching is usually worse at night, 
in damp weather and after excitement. 

Diagnosis. — In dealing with senile pruritus we must first 
eliminate other forms of pruritus. This is comparatively easy 



SENILE PRURITUS 1 55 

when it accompanies internal diseases or when due to pruritic 
dermatoses presenting surface lesions. There are no lesions in 
senile pruritus unless excoriation, dermatitis or eczema is pro- 
duced by scratching. In these cases the irritation long preceded 
the scratch lesion. 

Pediculi and the acarus are the principal dermal parasites 
and when present are found without difficulty in the locations 
which they infest. 

The thread worm, oxyuris vermicularis, though rare in the 
aged, may be present and give rise to an intolerable itching about 
the anus. It is often difficult to determine the cause if the pru- 
ritus is due to some local irritant. The most frequent source 
of such irritation is acid or acrid perspiration, sometimes woolen 
or flaxen underwear will cause it, occasionally handling irritating 
substances will produce it. In all cases in which there is a 
dermatitis or a local hyperemia not due to rubbing we can ex- 
clude senile pruritus. It is sometimes impossible to decide 
when the pruritus is due to psychic causes. In one institution 
where several sufferers from pruritus charged the original case 
with spreading phthiriasis among them, it was necessary to iso- 
late all patients and scrub them, although none had pediculi. 

Treatment. — There is no specific treatment for senile pruri- 
tus. The same measures which are apparently successful in 
some cases are detrimental in others, while in some cases the 
itch wiU suddenly disappear after all treatment had been dis- 
continued. The only drug which can be depended upon to give 
temporary relief is cocaine in a 2 per cent, ointment, using lano- 
line or sweet butter as a base. Occasionally a single application 
will give permanent relief, usually, however, the itch returns in 
a few hours. In some cases hot water, in some again cold water 
applications are of service. Ice and freezing mixtures will re- 
lieve the itching but may produce frost bites followed by gan- 
grene. Weak acid solutions, alkaline solutions, menthol, thymol, 
irritants like capsicum and cantharides, sedatives like bella- 
donna, stramonium and chloral, have all been recommended and 
the faradic current has been employed with benefit. In a dis- 
ease of this character, with unknown etiology and pathology, 
with a single distressing symptom, our efforts must be directed 
to the relief of that symptom and such measures can be used 
but empirically. 



156 PATHOLOGICAL OLD AGE 

VARICOSE VEINS 

Varix is the most frequent affection of the veins in old age 
and a mild type becomes physiological with advancing years. 
As the senile changes in the heart and blood-vessels proceed, 
the venous circulation becomes slower the veins become over- 
filled and they dilate. 

Etiology. — The normal varix of old age is seen in the super- 
ficial veins of the hands and feet. When this is excessive or 
due to other causes than the normal changes in the veins and the 
slackened venous circulation it is pathological. The most fre- 
quent site of this form of varix is about the lower limbs. It is 
found mostly in women who have had children and is then car- 
ried over from maturity. Among men it is generally found in 
those who stand or walk much. Arteriosclerosis and phlebo- 
sclerosis is generally present and it is believed that in almost 
every case there is an obstruction to the return circulation due 
to tricuspid stenosis. (Hemorrhoidal varix will be treated 
under Hemorrhoids.) 

Pathology. — The vessel becomes longer and dilatation occurs 
generally just above the valves. The vein assumes an irregular 
or wavy line with a single globular enlargement or there may be 
a series of dilatations giving the vessel a beady appearance. 
In some cases the dilatation extends in an unbroken line for 
some distance along the vein. The coats are generally hyper- 
trophied except at the dilated portions which are thin. Cal- 
careous plaques are sometimes found in the walls and thrombi 
form in the dilated pouches. 

Symptoms. — The veins present the familiar dark blue, wavy 
or irregular appearance seen upon the hands of the aged. Where 
the varicosity is pronounced the vessel appears swollen at one 
place, or there may be a string of such swellings, or the swellings 
may be scattered showing that several vessels are involved. 
The leg feels heavy and after long standing a hypostatic edema 
sets in about the ankles. 

Varicose veins are subject to many complications. The 
more important ones are pruritus, eczema, erysipelas, thrombus 
rupture and ulcers. Eczema is generally the result of scratching 
or rubbing where there is an intolerable pruritus and the same 
cause may be followed by rupture, ulcer and erysipelas. 



THROMBOSIS AND EMBOLISM 1 57 

Treatment. — Mild varicosities require no treatment. When 
pronounced the treatment is either radical by surgical procedure 
or palliative by means of bandages. There is some danger in 
rubber bandages, as they may compress the arteries as well as 
the dilated veins and cause impaired nutrition of the limb, un- 
less they are applied evenly and with just enough tension to 
compress the varix without compressing the limb. A close 
fitting rubber stocking is better. For the intolerable itching a 
2 per cent, cocaine lotion or ointment can be used. Sometimes 
ice will give relief, but the usual antipruritic remedies are gener- 
ally worthless. If the pruritus is relieved, the eczema can usu- 
ally be cured by the application of stearate of zinc, oxide of 
zinc or bismuth subnitrate. As long as the pruritus exists no 
treatment of the eczema will avail as it will be impossible to 
keep the patient from scratching. 

Hemorrhage from rupture is generally controlled without 
difficulty by compression below the site of rupture. Owing to 
the slowed circulation a clot will be speedily formed and if care 
is taken to prevent infection repair will take place. (Erysipelas 
is treated under the Infectious Diseases and Ulcer under Diseases 
of the Skin.) 

SECONDARY SENILE DISEASES 

The diseases of the second group are always secondary al- 
though the primary condition may be so obscure as to be 
unknown or unnoticed before the secondary disease appears. 
Typical examples of this group are apoplexy, senile gangrene, 
and angina pectoris. 

THROMBOSIS AND EMBOLISM 

These occur rather frequently in the aged. Though usually 
described together they differ so greatly in their etiology, path- 
ology, symptoms and prognosis that they will be considered 
separately. 

THROMBOSIS 

Etiology. — Thrombosis may be due to damage to the lining 
membrane of the vessel, to slowed circulation, or to a change 
in the character of the blood whereby its coagulability is in- 
creased. In old age, all three causes usually prevail, thus ac- 



158 PATHOLOGICAL OLD AGE 

counting for its frequency at that period of life. It may occur 
in either arteries or veins, the latter being more often affected, 
the circulation being slower there; especially is this the case in 
the lower extremities and in the brain. The damage to the 
vessel is usually due to an arteriosclerosis or fatty degeneration, 
the site of the lesion being the focus for the deposit of the agglu- 
tinated blood cells which form the primary thrombus. Vari- 
cose veins are frequently the seat of thrombosis. Other causes 
less prevalent in the aged are inflammation, toxemia, dilatation 
of the vessel or of the heart. Some of the infectious diseases 
cause thrombosis, either by direct effect of the toxemia upon 
the lining membrane of the vessel or by changing the character 
of the blood by which its viscosity is increased. 

Slowed current may be due to cardiac dilatation or weakness, 
or to dilatation of the vessels as in varicose veins. The senile 
changes in the blood are unknown. Its viscosity is increased 
and its coagulability is consequently greater than in maturity 
but it is uncertain whether there are other changes also which 
tend to cause agglutination of the cells and adhesion of the 
blood plates to the walls of the vessel. Traumatic causes, as 
compression of a vessel, may produce thrombosis and thrombi 
are frequently found in the heart, either as small vegetations 
or as adherent coagula. These are probably formed shortly 
before death. 

Pathology. — Whether occurring in an artery or in a vein the 
pathological process is the same. In the normal flow the red 
cells and blood plates keep to the center of the stream while 
the white cells travel along the wall of the vessel. When the 
circulation is slowed the plates leave the center and accompany 
the leucocytes. They will either adhere to the healthy endo- 
thelium or, finding a spot which is broken down, this spot becomes 
then the focus for the thrombus. The fibrin element parting 
from the plasma, the plates and the fibrin form the primary 
layer or primary thrombus upon which layer after layer of 
plates and fibrin are deposited. The caliber of the vessel is 
diminished and it may be entirely obliterated. This usually 
proceeds slowly and in many cases collateral circulation is fully 
established before complete obliteration takes place. When 
occurring in a terminal artery, the tissue supplied from the 
vessel beyond the occlusion is deprived of nutrition and in- 



THROMBOSIS 159 

farction results. In some cases the thrombic formation proceeds 
so rapidly that complete occlusion occurs before any compen- 
satory collateral circulation is established and gangrene results. 
This occurs most frequently in thrombosis following infectious 
diseases and is rare in the aged. In venous thrombus there is 
passive congestion and edema of the part below the occlusion. 
The thrombic deposits are sometimes removed by a process of 
softening, while sometimes they become organized and form 
part of the vascular wall. In some cases particles are torn off 
and are carried in the circulation as emboli. 

Symptoms. — The symptoms of thrombosis depend upon the 
location and rapidity of formation. 

The most frequent location of thrombosis in the aged is in 
one of the cerebral vessels. (The symptoms are described 
under Cerebral Softening while cardiac thrombosis will be de- 
scribed separately.) 

Venous thrombus occurs most frequently in the veins of the 
lower extremities, occasionally in the cerebral sinuses and veins, 
rarely in other veins. In the aged the most frequent cause of 
venous thrombus is phlebosclerosis with slowed circulation, 
rarely a phlebitis. In the lower limbs the usual location is in 
the dilated portions of a varicose vein. Sometimes the deposits 
can be felt as hard lumps which cause pain when pressed upon. 
There is generally pain and edema upon standing, both sub- 
siding when the limb is in a horizontal position. If there is a 
phlebitis the pain is constant and severe, the edema is exten- 
sive, there is fever and other symptoms of inflammation and 
the thrombosis progresses rapidly. Phlebitis is, however, very 
rare in old age and when it does occur it is almost always due 
to traumatism. The principal danger from venous thrombus 
lies in the detachment of particles which are carried to the 
heart and then to the lungs as emboli. 

Sinus thrombosis is rare in the aged, and when occurring it 
is almost always secondary to an injury, inflammation or other 
pathological condition in or about the skull. Primary throm- 
bosis of the longitudinal sinus has been found upon autopsy 
which gave no symptoms during life and for which no cause 
could be found. There are no clearly defined symptoms point- 
ing to this disease. There is usually headache, dizziness, mental 
depression; there may be convulsions, hemiplegia, and other 



l6o PATHOLOGICAL OLD AGE 

cerebral symptoms, but all these may be due to the primary 
disease or may be associated with other conditions. Fulness 
of the veins of the face and head and local edema are fairly 
indicative of sinus thrombosis but they are not always present. 
In many cases the disease is of septic origin and then there will 
be a jugular phlebitis with symptoms of pyemia. 

Treatment. — (The treatment of gangrene, cerebral softening 
and cardiac thrombus will be given under those heads.) The 
treatment of sinus thrombus is surgical and must be directed 
to the causative condition. In the venous thrombosis of the 
lower extremity, if due to phlebitis, the latter must be treated. 
Absolute rest, the limb being rendered immobile by splints, is 
imperative. Local applications of hot water or hot lead water 
should be made. If there is an underlying septic condition 
that must be treated, and if these measures fail surgical inter- 
ference may be necessary. If the thrombus forms in a varicose 
vein, rest and the application of tincture of iodine or iodide of 
potassium ointment, with strapping of the limb, may effect a 
cure. 

Cardiac Thrombosis 

At almost every autopsy a clot is found in the heart. It is 
probable that most clots are formed shortly before death when 
blood changes favor coagulation and the slow current permits 
their adhesion to the walls of the cavities. In many cases, 
however, the clots are evidently of long standing, firm and closely 
adherent to the walls. 

Etiology. — The causes of cardiac thrombi are obstruction 
to the passage of blood through the heart as in valvular defects, 
slowing of the current through dilatation or atonicity of the 
myocardium, change in the character of the blood whereby its 
coagulability is increased as in infectious diseases, nephritis, dia- 
betes, etc., and roughening of the endocardial surface. Small, 
firmly adherent, slowly developing thrombi, called vegetations, 
occur frequently after rheumatism and in the various valvular 
degenerations. 

Pathology. — The vegetations are usually fibrinous adhesions 
to the valves or cordse tendinae. They are of the same con- 
sistency as the adjoining tissue, lighter in color with irregular 



EMBOLISM l6l 

edges. Larger and more recent thrombi may reach the size of 
a walnut and may be found in any cavity. They may be firm 
but are usually soft and jelly-like, while in diseases running a 
rapidly fatal course they are very soft. Older thrombi consist 
of exsanguinated fibrin, are light in color and are usually closely 
adherent to the endocardium. 

Symptoms. — The vegetations rarely give any pronounced 
symptoms except where they extend beyond the edges of valves 
and thus produce stenosis. The symptoms then are the symp- 
toms of valvular stenosis. If a thrombus forms rapidly and is 
of large size it may cause a speedy fatal end by complete obstruc- 
tion of the cardiac circulation. If smaller or developing more 
slowly there is dyspnea, cyanosis, partial syncope, irregular 
and weak heart action, hurried respiration, restlessness and 
anxiety, later cerebral symptoms, pulmonary edema and finally 
coma. In some cases death occurs in a few hours. A small 
thrombus may give less severe symptoms but the condition is 
always grave and generally fatal. 

Treatment. — There is no known treatment for this condi- 
tion. The alkaline carbonates are supposed to have the power 
to prevent coagulation but neither these nor the iodide of 
potassium relieve the symptoms or prevent death when a large 
thrombus has formed. In milder cases rest and small doses of 
digitalis and opium may be tried. 

EMBOLISM 

EmboHsm occurs more frequently in the aged than in earlier 
life, as some of the principal sources of the embolus are mainly 
found in the aged. It may be, moreover, directly responsible 
for several senile pathological conditions, such as cerebral 
softening, senile gangrene, etc. 

Etiology. — Embolism is a secondary disease, the plug itself 
being a pathological product of some other disease. It may be 
a fragment of a blood clot detached from a thrombus, a particle 
of calcareous or other matter from an atheromatous plate, 
vegetation from the endocardium, a piece of neoplasm, a mass 
of bacteria or a mass of pigment. It may be a fat embolus, or 
hyaline matter or any other substance that has made its way 
into the circulation. The plug is carried in the circtilation, and 
if coming from a vein or the right side of the heart, it lodges in 



1 62 PATHOLOGICAL OLD AGE 

the pulmonary artery or in one of the branches ; if coming from 
the left side of the heart or from an arterial source it is carried 
to some smaller vessel, which it blocks. Thrombic or athero- 
matous fragments or vegetations may become detached when 
the heart action is suddenly increased by exercise, drugs or 
a sthenic inflammation and the blood current is sent through 
the diseased vessel with greater force. 

Pathology. — Plugging of an artery or arteriole causes anemia 
and degeneration or gangrene of the tissues supplied by the 
part beyond the plug, unless anastomosis and collateral circula- 
tion is speedily established. In embolism of smaller vessels 
and arterioles, except in terminal arteries, anastomosis generally 
occurs. If a larger vessel is blocked or when it is a terminal 
vessel, infarction, degeneration or gangrene follows, or it may 
cause complete functional arrest and death as when the pul- 
monary artery, coronary artery or one of the larger cerebral 
vessels is blocked. In some cases the lumen is not completely 
plugged by the embolus. Fibrin is then deposited upon it 
and a thrombus is formed which may completely block the ves- 
sel. If this occurs in a larger vessel the part beyond the plug 
is not immediately cut off from nutrition and collateral circula- 
tion may be established before the lumen is closed entirely. 

Symptoms. — Pulmonary embolism occurs when the pulmo- 
nary artery or a branch is blocked. The embolus is either 
carried from a vien, being a detached portion of a thrombus, 
or it originates in a vegetation of the right heart. In old age 
when the venous circulation is normally weak, degeneration 
of the endocardium of the right heart leads to the formation of a 
thrombus which may become dislodged by a powerful cardiac 
contraction and carried to the pulmonary artery or may oc- 
clude one of its branches. If a main branch is blocked there 
will be instant collapse and death. If a small vessel is closed 
up a hemorrhagic infarction will result. This begins with a 
sudden, severe pain, dyspnea, a feeling of oppression and anx- 
iety, sometimes a chill. The heart is weak, there is usually cya- 
nosis and blood-streaked expectoration and there may be small 
blood clots in the sputum. The severity of the symptoms varies 
with the extent of pulmonary involvement, a minute infarction 
giving no pronounced symptoms except perhaps the expec- 
toration of small blood clots. Dark scanty hemoptysis is the 



EMBOLISM 163 

pathognomonic sign of pulmonary infarction (Loomis). The 
condition is serious even with a small infarction. Embolism in 
the brain produces cerebral softening which will be described 
separately. 

Portal embolism may occur from embolic matter brought from 
the stomach, intestines, spleen or pancreas. The free anasto- 
mosis of the portal and hepatic systems whereby rapid collateral 
circulation is established prevents the formations of infarctions. 
Portal embolism gives no symptoms unless there is complete 
occlusion, when the symptoms are the same as in the hepatic 
obstruction of cirrhosis of the liver. 

Renal embolism produces renal hemorrhagic infarction. The 
embolus generally comes from a fragment of endocardial or 
valvular vegetation which was torn away by some powerful 
cardiac contraction as after exercise, or from the loosening of 
some atheromatous matter. The symptoms are fever, an ache 
or pain in the the region of kidneys coming on suddenly and 
persisting, blood in the urine, and symptoms of cardiac disease 
or arteriosclerosis. 

Femoral embolism is rare in old age. When it does occur 
there is a sudden severe pain, the limb is blanched and numb, 
followed by complete loss of sensation and motion. If the 
occlusion is complete and collateral circulation is not rapidly 
established gangrene sets in, beginning in the foot and extending 
upward. Partial occlusion or incomplete collateral circulation 
causing imperfect nutrition of the part beyond, will result in 
atrophy of the limb with impaired motion and sensation. Em- 
bolism of a branch of the femoral or in another vesssel of the 
lower extremity produces the same result, the extent depending 
upon the extent of the occlusion, the rapidity and extent of the 
collateral circulation and the amount of tissue which has been 
deprived of nutrition. 

Air Embolus. — This occurs when air enters a vein. If it is a 
minute globule it produces a momentary "arrhythmia on reaching 
the heart. A larger amount of air will produce a spasm of the 
heart and may cause fatal collapse. 

Mountain Sickness. — The rapid ascent of high altitudes is 
liable to produce cardiac thrombosis and pulmonary embolism 
in aged persons. The attack may occur several days after the 
descent and is fatal. 



164 PATHOLOGICAL OLD AGE 

Treatment. — A large pulmonary embolus is rapidly fatal. 
If it is a small embolus causing an infarction, our main reliance 
is in absolute rest and the treatment of symptoms as they arise. 
Cardiac stimulants are contraindicated as they may dislodge 
further emboli. If the circulation is weak, hot water should be 
applied to the feet, and dry cups and sinapisms to the back and 
chest. If there is great dyspnea morphine and atropia should 
be used. When the acute symptoms subside iodide of potassium 
should be given to promote absorption. 

No treatment is required in a portal embolism. If complete 
occlusion occurs it should be treated the same as cirrhosis of the 
liver. 

In renal embolus, tannic acid in 5 -grain doses will control 
the hemorrhage, but ergot, which is of service in this disease in 
earlier life, is inadmissible if there is arteriosclerosis. Diuretics 
are contraindicated. Iodide of potassium may be used in small 
doses to secure absorption and elimination of the degenerated 
tissue. 

In embolism of the femoral or other artery of the lower ex- 
tremity, active local hyperemia should be produced and main- 
tained to stimulate collateral circulation. If this fails and gan- 
grene sets in surgical interference will alone avail to save the 
limb or the patient. 

SENILE GANGRENE 

Senile or atheromatous gangrene is a dry gangrene due to 
tissue starvation through an obliterating arteriosclerosis. The 
dry gangrene following embolism, thrombus, traumatism or 
chilling of the surface, does not differ in pathology or symptoms 
from the other and when occurring in the aged is included in the 
term of senile gangrene. Moist or septic gangrene which is due 
to infection or to diabetes is not strictly a senile gangrene but 
will be included here for the sake of continuity of description. 

Etiology. — The cause of senile gangrene is the closure or 
obliteration of a vessel where collateral circulation is not rapidly 
established. This may occur as the result of an arteriosclerosis 
or embolus, less frequently a thrombus. It may also occur when 
the surface has been chilled and the circulation is poor, the ves- 
sels contracting and the circulation ceasing in the part involved. 



SENILE GANGRENE 1 65 

Traumatism may cause gangrene through injury to a vessel or 
through pressure upon a part, as occurs in bedsores. In this 
case there may be either destrviction of the part through direct 
compression or through the compression of the nutrient vessels. 
In many cases of senile gangrene there is a history of gout, 
rheumatism, syphilis, alcoholism, or infectious disease, all causes 
for chronic endarteritis with consequent thrombosis or embolism. 
Some are the terminal stage of Raynaud's disease. Moist 
gangrene may follow an infectious disease, infection of a surface 
lesion or some disease like diabetes, nephritis, or cerebral disease 
which diminishes the resistance to infection. 

Senile gangrene occurs most frequently in one of the lower 
extremities, generally in a foot or toes, occasionally in an upper 
extremity, rarely in two membranes at the same time or in other 
parts of the body, except when frozen or injured. 

Symptoms. — The earliest symptoms of senile gangrene is a 
tingling or feeling of numbness in the part, the part becomes 
pale and cold and later it is livid. If occurring in the foot, the 
latter feels heavy and cold and its sensibility is diminished. 
After a time a brownish or purplish spot or patch appears, which 
increases in extent and becomes darker until it is almost black. 
The skin over this area is dry, hard, and leathery, and may ex- 
foliate. The area involved is insensible to pressure or punctures, 
sensation and motion being completely lost. The tissues be- 
come mummified. The destruction proceeds until all the tissues 
in which the blood-supply was cut off are involved. In most 
cases there is a line of demarkation where the gangrene stops 
and the part destroyed falls off. In some cases there is no line 
of demarkation and the destruction of tissue proceeds in all 
directions. This occurs more frequently in moist gangrene. In 
this form the tissues become soft and pulpy and putrefy with 
the formation of pus. There is the odor of decomposition and 
the tissue resembles the slough of an ulcer. There is usually 
some pain in the beginning but this soon gives way to tingling 
numbness and insensibility. In septic gangrene there are the 
usual symptoms of septicemia, rigors, irregular fever, perspi- 
ration, rapid pulse, some stupor and typhoid symptoms. 

Senile gangrene due to thrombus or arteriosclerosis proceeds 
slowly, the paling and tingling being so slight at the beginning 
as to barely attract attention, gradually becoming more intense. 



1 66 PATHOLOGICAL OLD AGE 

The gangrene due to embolus generally begins with a sharp 
pain followed by tingling or numbness, and the disease pro- 
gresses rapidly. The prognosis is good as to life if a line of de- 
markation is formed and the area involved is small. Aged per- 
sons have recovered after amputation at the hip -joint. As for 
the part involved the prognosis is unfavorable. It is some- 
times possible to arrest the disease with but slight loss of tissue ; 
even complete recovery has been effected. Moist gangrene 
proceeds rapidly, there is no line of demarkation and it is almost 
always fatal. 

Treatment. — The treatment depends upon the cause and 
the stage of the disease. Tissue that has already become gan- 
grenous must be removed. If septic symptoms appear rapid 
excision or amputation is imperative. Temporizing is fatal in 
such cases. In the early stage of dry gangrene it is sometimes 
possible to bring about rapid collateral circulation by applying 
hot water constantly to the part. It should not be raised. 
In the gangrene following arteriosclerosis, iodide of potassium 
should be given in 5 -grain doses every four hours until the 
physiological effects of iodism appear, in order to produce 
lessened viscosity of the blood. 

If it is a frozen part heat should be applied gradually and 
the tissue massaged. When operation becomes necessary, if 
there is no line of demarkation, amputation must be performed 
at the joint above the lesion. 

CARDIAC NEUROSES 

These are functional disorders involving temporary or per- 
manent change in force, frequency or rhythm of the heart. 
These anomalies are in some instances symptoms of organic 
disease of the heart itself or of the coronaries, or of gastric 
or cerebral disturbance, fever, toxemia, pain, etc.; in some 
cases they are due to non-pathological causes, such as meno- 
pause, high altitudes, hot baths, exercise, excitement or exhaus- 
tion, the use of tea, coffee, tobacco, etc. They may also be 
due to senile changes in the nervous regulation of the heart 
either in the vagus or in the intrinsic ganglia, or to some altera- 
tion in the muscular structure. The heart beats should be 
counted and their character determined at the heart and not 



I 



PALPITATION 167 

at the radial pulse, as radial arteriosclerosis may alter the 
character of the latter, or beats may be lost between the heart 
and wrist, or the ventricular contraction may be so weak 
that the impulse is not carried with sufficient force to distant 
vessels to give a palpable pulse. The pulse, moreover, gives 
no indication of the condition of the auricles. 

When these changes in the force, frequency or rhythm of 
the heart are due to diseases presenting anatomical lesions, 
as in valvular disease, or are symptoms of clearly defined path- 
ological conditions, such as fever, they cannot be considered 
as neuroses. It is, moreover, probable that every neurosis is 
dependent upon some temporary or permanent change in the 
structure or character of the tissue, the function of which 
is impaired. So long as we have not determined what that 
change is, we class such functional disturbance as a neurosis or 
psychosis. 

Palpitation 

This is an alteration in the force, frequency or rhythm 
of the heart which becomes noticeable to the individual. 

Etiology. — When permanent, it is a symptom of organic 
heart disease, exophthalmic goiter, or a continuance of a non- 
pathological cause, as excessive smoking, tea, coffee, alcohol, 
sexual indulgence, etc. 

Temporary palpitation of the heart may be due to any of 
the non-pathological causes mentioned, to other neuroses, to 
upward pressure upon the diaphragm from a distended stomach, 
irritation of the nervous system, strong emotions, even pleas- 
urable anticipation, or abnormal condition of the blood as in 
anemia, uremia, or other toxemias. It also occurs in uterine 
and ovarian disorders. In some cases no cause can be found. 

Symptoms. — The pathognomonic symptom is a more or less 
violent thumping, beating or fluttering of the heart perceptible 
to the patient. When due to organic heart disease there is 
generally, arrhythmia with the other symptoms of the under- 
lying condition. In exophthalmic goiter there are the symp- 
toms of that disease. When due to other causes there is gener- 
ally a tachycardia lasting as long as the palpitation lasts. Other 
symptoms depend upon the cause. If due to gas distending 



1 68 PATHOLOGICAL OLD AGE 

the stomach and pressing upward upon the diaphragm, there 
will be eructations with relief from the palpitation. In anemia 
there will be an anemic bruit at the base of the heart. Shock 
and fright will leave the face pale; in excitement the face will 
be flushed. There may be nervous or hysterical manifestations, 
dyspnea, etc., attributable to the cause of the palpitation. If 
there is no organic lesion, the physical signs may be negative, 
perhaps nothing more than increased frequency or force of 
heart action. 

Treatment. — The treatment of palpitation of the heart 
depends upon its cause. If it is distressing and the cause 
cannot be removed, an ice bag over the heart and 15 grains of 
bromide of sodium will often give relief. If there is consider- 
able mental agitation, 5 to 10 grains of veronal and 5 grains of 
monobromated camphor should be given. If these do not 
give relief a hypodermic injection of J grain of morphine and 
rio" grain atropia should be used. In all cases the cause must 
be removed if possible. In many senile cases the cause can 
be traced to a distended stomach and rapidly acting cathartics 
are required. In high altitudes the patient should practice rapid 
and deep breathing. Drugs are rarely required except during 
a severe attack. 

Bradycardia 

A pulse rate of 50 to 60 a minute is natural to many aged 
individuals and is generally due to increased arterial tension, 
the heart acting slower but more powerfully to overcome the 
increased resistance of the vessels. 

Etiology. — The most frequent cause of bradycardia in the 
aged has just been stated. It may also occur in organic heart 
disease, more especially in cardiac degenerations, irritation of 
the vagus, in various toxemias, in convalescence from exhaust- 
ing diseases, in chronic diseases, in exhaustion, inanition, sun- 
stroke, syncope, meningitis, apoplexy, etc. As a pure neurosis 
it occurs with other neuroses and some psychoses, especially 
with neurasthenia, melancholia, hysteria, epilepsy and paresis. 
(Heart block, in which bradycardia is a prominent symptom 
will be described separately.) 

Symptoms. — The pathognomonic symptom is a diminished 



I 



TACHYCARDIA I 69 

frequency of the action of the heart. The beat should be 
counted at the heart and never at the radial pulse. Other 
symptoms belong to the causative condition. 

If persistent it is a symptom of organic heart disease, irrita- 
tion of the vagus, exhaustion, convalescence, etc. Temporary 
bradycardia may be due to syncope, pain, toxemia and mental 
depression. 

Treatment. — The treatment depends upon the cause. It 
is rarely necessary to institute treatment for the bradycardia 
itself, as it gives no distressing symptoms and it will disappear 
or improve with the arrest or improvement of the cause. 

Tachycardia 

Rapid heart action is sometimes natural to the individual 
and cases have been reported in which there was a heart beat 
of 115 to 130 a minute without distress and without any other 
symptom or sign pointing to a pathological condition. 

Etiology. — In the aged tachycardia is frequently associated 
with coronary sclerosis. All the causes that may give rise to 
palpitation may produce rapid pulse. It is present in fevers, 
goiter, hemorrhage or tumor at the base of the brain, various 
forms of heart disease and it may be produced by drugs which 
either stimulate the sympathetic or inhibit the vagus. Tachy- 
cardia being a symptom rather than a disease, the pathology 
depends upon the underlying causative condition. A perma- 
nent tachycardia may be physiological, an intermittent one is 
always pathological. 

Symptoms. — Tachycardia is itself a single symptom, rapid 
heart action. When it becomes noticeable to the patient it is 
called palpitation. There are usually incidental symptoms 
belonging to the underlying cause. There is sometimes a 
precordial distress and in those cases in which it is natural 
to the individual, slight exertion, or emotion will produce 
palpitation. 

Treatment. — The treatment depends upon the cause. If 
no cause can be found in permanent tachycardia and the indi- 
vidual is in good health nothing should be done. If inter- 
mittent and no cause can be found, the patient should lie down 
with an ice bag placed over the heart. If the organ is strong 



lyo PATHOLOGICAL OLD AGE 

and the sounds are clear, 5 -minim doses of tincture of aconite 
should be given. If the heart sounds are weak, 2 -minim doses 
of aconite combined with 1/50 grain of strychnine should be 
used. Tincture of digitalis is useless as its action is too slow. 
Gelsemium or veratrum viride may be substituted for aconite in 
the same dose. The treatment of palpitation also applies to 
tachycardia. 

Adams-Stokes Disease 

This is a form of transmittory arrhythmia in which epileptoid 
attacks occur at irregular intervals. 

Etiology. — It occurs most frequently in cases of arteriosclero- 
sis, occasionally in cases having a history of syphilis or rheuma- 
tism. Neither the cause of the disease nor that of the attacks 
is known; the attacks have occured when the patient had 
been at complete rest or even in bed for several days and also 
after slight or intense excitement. 

Pathology. — In most cases a lesion in the bundle of His has 
been found, but pathologists have reported autopsies of cases 
that had shown the symptoms of the disease, without finding a 
lesion which could stand in a causal relation to it. On the 
other hand McElroy reported a case that on autopsy showed 
almost complete destruction of the bundle of His by a gumma, 
yet there was no symptom or evidence of the disease during 
life. 

Symptoms. — Before the first attack and between attacks a 
bradycardia may be the only symptom pointing to the disease 
and the patient himself may be unconscious of it. There is 
usually a jugular pulsation or wave much more frequent than 
the heart beat, the usual relation of the two being three to one. 
The attack comes on suddenly with tinnitus, vertigo and 
syncope, the pulse being extremely slow and weak, lasts a few 
minutes and the patient recovers feeling weak and as though 
he had just escaped death. It is probable that many cases of 
sudden death in the aged are due to an attack of this disease. 

Treatment. — The treatment is entirely symptomatic. 
Where a cause can be found, that cause should receive atten- 
tion. The usual hygienic measures applicable to arteriosclero- 
sis should be employed. During the attack a hypodermic 




Adams-Stokes disease, showing the patient just recovering from a syncopal attack, with 
rapid pulsation visible in the depression above the clavicle. From " Heart Disease and Blood 
Pressure" by L. F. Bishop, M. D. (Funk & Wagnalls, New York.) 




8 Seconds 



Tracing of the jugular and radial pulses during eight seconds. 
(From "Heart Disease and Blood Pressure" by L. F. Bishop, M. D. 
(Funk & Wagnalls, New York.) 



Nodule 




Photograph of Heart in a case of Adams-Stokes disease — showing Calcareous 
nodules (center of picture just below the aortic valves) in the region of the bundle 
of His. (From 'Heart Disease and Blood Pressure'' by L. F. Bishop, M D. 
(Funk & Wagnall's, Xew York.) 




I I II I I I t t I i I I I I I I I I I I i 



••■■••••'■•'• 



A. Complete Arrhythmia. Fibrillation of the Auricle (Courtesy of L. F. Bishop, M. 
D., New York.) B. Same case ten days later under influence of Digitalis. 




Jugular 



Brachial 



^Second 
I « » ' ' I ' ' « ' ' I — I I — I — I I I I I i — 

Extrasystole. (Tasker Howard, M. D., Xeiv York Medical Journal, May 

3, 1913-) 



hJ\j-K!\hh- 




BRACHM 



>^ Second 
- ' 1 » ' ■ ' ' ■ I I 1 I I — I — L— I — I — I L-L.-l^ 

Auricular Fibrillation. (Tasker Howard, M. D,, New York 

Medical Journal, ]\Iay 3, 1913.) 



C C C . c r 




Jugular 



Inspiration 



Expiration 





Brachial 



*/o Second 



J I I 111*11 



Sinus Arrhythmia. (Tasker Howard, 2vl. D., Xew York Medical Journal, 
May 3, 1 9 13.) 



ARRHYTHMLA. I 7 I 

injection of atropia 1/120 grain and spartein 1/4 grain should 
be given. Digitalis is contraindicated but strychnine in 
i/30-grain dose can be given. 

Arrhythmia 

Irregularity in rh^-thm is frequently found in the aged, 
generally in connection with organic heart disease. The 
irregularity may be in rate or force or both, temporar\', pro- 
longed or permanent. As the disturbance in cardiac action is 
transmitted to the radial arter\^ thereby affecting the character 
of the pulse, the various forms of arrhythmia have been desig- 
nated by the type of pulse, paradoxical, bigeminal, trigem- 
inal, respirator}^ extrasystoHc, alternating, etc. As the radial 
pulse in the aged is, however, affected by many factors besides 
the action of the heart and is therefore unreliable for diagnos- 
tic purposes, the terms usually applied should not be used to 
designate the character of the arrhythmia. 

Complete Arrhythmia. — In complete arrhythmia there is a 
disturbance in the force and rate of cardiac action, without 
periodicity or regularity of sequence. In the sphymographic 
tracings no two successive beats are alike. This condition is 
foimd in auricular fibrillation, complete loss of compensation, 
advanced exophthalmic goiter and may be produced by digitalis 
or thyroid extract. The irregularity may be extreme producing 
delirium cordis or it may be so mild as to be unnoticed and un- 
known until an examination of the heart is made. 

Partial Arrhythmia. — In incomplete or partial arrhythmia 
there is a periodicity or regularit}' of sequence in the irregularity 
of rate, or force or both. It ma^' be ph^'siological or patho- 
logical. 

In physiological or respiratory arrhythmia, the beats are 
accelerated and stronger during inspiration and slowed with 
expiration. Normally the difference is verj shght. 

Exaggerated respiratory arrhythmia, the sinus arrhythmia 
of !Mackensie, in which the difference becomes marked, occurs 
in neurasthenia, convalescence and in cerebral diseases. The 
force may be lessened when the rate is increased during inspira- 
tion, as in pericarditis and weak heart. The pulse is then 
caUed paradoxical pulse. Exaggerated respirator^' arrhythmia 



172 PATHOLOGICAL OLD AGE 

is supposed to be due to a change in the irritabihty of the vagus 
center in the medulla and can be controlled by atropia. The 
arrhythmia is increased by forced breathing and diminished by 
holding the breath. 

Extrasystolic Arrhythmia. — In this form there is a second 
systolic beat rapidly following the first or normal systole with 
a consequent prolonged diastole. Meltzer devised the formula 
that the diastolic pause between the normal and extrasystole 
plus the diastolic pause following the extrasystole equals two 
systoles. The extrasystole is not a supernumerary but an 
accelerated beat since the following contraction occurs in its 
normal time. There may be a second or even a third acceler- 
ated systole but true to Meltzer's formula the succeeding 
diastole will be lengthened so that the sum of the diastoles will 
equal the sum of the normal diastoles. This form of arrhythmia 
gives rise to the bigeminal, trigeminal, etc., forms of pulse. 

The studies of Traube, Gaskell, Mackensie, Wenckebach, 
Meltzer and others have cleared up many questions as to the 
origin of the extrasystole but the nature of the stimulus which 
produces it in man is still unknown. It occurs most frequently 
in hysterical and neurasthenic individuals, occasionally in 
arteriosclerosis. The diagnosis of this form of arrhythmia is 
not difficult, there being two, rarely three or more, beats follow- 
ing each other rapidly and then a correspondingly long pause. 
The patient may feel a hard thump or heart beat corresponding 
to the extrasystole (which is usually louder than the normal 
first sound), others may feel a momentary faintness as though 
the heart stopped, corresponding to the prolonged diastole. 
The diagnosis can be confirmed by the sphymograph and 
cardiograph. 

Transmittory Arrhythmia. — This form of arrhythmia to 
which the name heart block has been given is caused by a dis- 
crepancy between the auricular and ventricular contractions 
due to impaired conductivity of the impulses through the bundle 
of His. In moderate disturbance, there may be only a retarda- 
tion of impulses causing an occasional loss of a ventricular beat. 
If the impairment is greater, frequent beats are lost either 
irregularly or at regular intervals so that every second or third 
beat is dropped. Still further disturbance may cause only one 
out of every two or three impulses of the auricle to reach the 



CL CL 




A n 




Jugular 



mm 



/wwwvy^ 



Brachial 



/5 Second 
« * » 1 > I i I > ^ ^ i , I , i — I — \ 

Alternating 'Arrhythmia. (Tasker Howard, M. D., New York Medical 
Journal, May 3, 1913.) 




Transmitting Arrhythmia. Partial Heart block. (Tasker 
Howard, M. D., New York Medical Journal, May 3, 19 13.) 



I 



ARRHYTHMIA 1 73 

ventricle or there may be complete dissociation between auricle 
and ventricle, the latter following a rhythm of its own. This 
is termed complete heart block. 

The impairment of the bundle of His may be due to senile 
degeneration, syphilis, toxemias, or it may be of neurotic 
origin. The independent rate of contraction of the ventricles 
is from twenty-three to twenty-eight per minute ; if the heart beat 
does not exceed this number there is a complete block. In 
Bishop's case in which there was a calcareous nodule in the 
region of the bundle of His the heart rate ranged from thirty- 
eight and forty on the first day to twenty on the last day. 
When transmittory arrhythmia is associated with epileptiform 
attacks it forms Adams-Stokes disease. 

Alternating Arrhythmia. — This is the pulsus alternans first 
described by Traube, in which the rate is regular but the force 
is irregular. There may be several strong beats followed by a 
weak beat, or strong and weak beats alternating or several 
weak beats with an occasional strong beat. The contractility 
of the muscle is impaired either permanently through degenera- 
tion of the myocardium or dilatation, or temporarily through 
acute disease or drugs. 

Galloping arrhythmia is a form of arrhythmia in which a 
third sound is heard with each beat of the heart. It is a redu- 
plication of one of the normal sounds usually the second and 
occurs immediately after the second sound or just before the 
first one, shortening the diastole. The sounds are suggestive 
of the hoof beats of a galloping horse. It may occur tempo- 
rarily when the heart is overworked; if permanent it is gener- 
ally due to the exaggerated rebound of hypertrophy with aortic 
arteriosclerosis. 

Embryocardia is a form of arrhythmia in which the first 
sound and the diastole are shortened, the rhythm being like 
the ticking of a clock. It is called the tick-tack heart and is 
heard when compensation is lost and in any condition leading to 
collapse. 

Treatment.— The treatment of the arrhythmias depends 
upon the cause. Only two types, delirium cordis and Adams- 
Stokes disease require emergency treatment during an attack, 
since they produce distress apart from the causative condition. 
In delirium cordis relief can usually be obtained from a hypo- 



174 PATHOLOGICAL OLD AGE 

dermic injection of atropia i/ioo grain and strychnia i/ioo 
grain combined with either 1/200 grain aconitine i/ioo grain 
strophanthin or digit aHne or i/ioo grain nitroglycerin, the 
selection depending upon their indications, high blood pressure 
and full rapid pulse demanding aconite, low pressure and 
weak rapid pulse requiring strophanthus or digitalis ; high pres- 
sure and slow weak or irregular pulse requires the nitrites. 
The nitrites should not be used if the face is flushed, digitalis 
should not be given if it has been used for a long time, and 
aconite should not be used if the pulse and heart beats are 
weak. In some cases the heart instead of pitching about with 
varying force and frequency will give an occasional jump like 
the expiring efforts of a fish out of water. This portends a 
speedy dissolution. Spartein in gr. 1/2 to gr. ii doses may 
momentarily strengthen the heart increasing the force and 
frequency of its contractions. 

(The treatment of Adams-Stokes disease is given under that 
head.) 

Extrasystole is sometimes due to an overloaded stomach 
pressing upward upon the diaphragm, thereby disturbing 
the heart. To empty the stomach by an emetic or the bowels 
by a rapidly acting cathartic is the first indication in these 
cases. 

If no cause for the arrhythmia can be discovered the treat- 
ment must be symptomatic. Rest and the avoidance of 
coffee, tea and tobacco are imperative. The greatest care must 
be taken in the selection of drugs. 

If there is considerable mental agitation 5-10 grains of 
veronal combined with 3 grains of camphor monobromate 
will relieve this condition. 

The ordinary hygienic measures rest, diet, hydrotherapy, 
massage, freedom from excitement, care of the bowels, etc., 
are necessary adjuncts. 

ANGINA PECTORIS 

Angina pectoris is a paroxysmal neurosis occurring most 
frequently in connection with coronary or aortic arteriosclerosis 
or aneurysm. It also occurs in myocardial degeneration, endo- 
carditis and other cardiac diseases. In some cases no patho- 



ANGINA PECTORIS 1 75 

logical causative factor can be found. vSometimes there is a 
history of gout, diabetes, syphilis, renal or hepatic disease, but no 
causal relations between them has been discovered. Occasion- 
ally the symptom complex occurs without the cardinal symp- 
tom of paroxysmal, precordial pain; this "angina sine dolore" 
is supposed to be of neurotic origin although any one of the 
above-mentioned causal conditions may be present. In func- 
tional angina pectoris, misnamed pseudo-angina, the under- 
lying cause seems to be a toxin or a neurotic condition, usually 
hysteria. 

Etiology. — Many theories have been advanced to explain 
the pathogenesis of angina pectoris yet none will apply to all 
cases. It is evident that there is more than one underlying fac- 
tor or else there are several conditions giving the same clinical 
manifestations. One theory is that it is due to sudden increase 
in tension in the ventricles. Vaso-dilators diminish cardiac 
tension and they generally give relief, but in some cases they 
aggravate the attack. The theory that it is due to myocardial 
ischemia caused by sclerosis or spasm of the coronary artery 
may apply to some cases, but patients have died during an 
anginal attack, yet upon autopsy no coronary disease was found. 
The toxin theory that the disease is due to toxemia holds good 
in but few cases. Heberden's theory that it is a cramp or spasm 
of the heart, brought on by an irritation of the heart muscle, 
does not hold good in these cases in which there is no change in 
the force or rhythm of the heart. McKenzie's theory that it 
is due to an impairment in the contractility of the heart is 
objected to for the same reason. 

One pathological condition is almost invariably present in 
angina pectoris — the stomach is dilated with flatus which is 
expelled at the moment that the attack ceases. The intimate 
relation between the stomach and the heart through the pneu- 
mogastric nerve will explain why gastric disorders are frequently 
reflected in cardiac irritation. An over distended stomach 
pressing upward upon the diaphragm causes direct irritation 
of the heart. In the normal, healthy heart this irritation causes 
arrhythmia, palpitation and precordial pain and often gastric 
asthma. If the heart is degenerated, this irritation causes either 
a spasm of the heart or the terminals of the vagus are irritated 
and they produce the characteristic agonizing pain by contract- 



176 PATHOLOGICAL OLD AGE 

ing the entire organ, or a limited area of the organ, at the 
same time compressing the sensory nerve endings. This would 
explain the most frequent cause of angina pectoris. Fear, 
shock, anger, etc., may act through reflex action upon the 
vagus, while tobacco and other toxins are direct irritants of the 
nerve. In all these cases irritation of the vagus is the under- 
lying or basic etiological factor. The true angina pectoris 
occurs most frequently in those past middle life and these 
generally have aortic or coronary arteriosclerosis and perhaps 
myocardial degeneration, and in addition there are probably 
changes in the intrinsic ganglia of the heart and in the pneumo- 
gastric and phrenic nerves due to impaired nutrition. This 
would account for the greater frequency, severity and danger 
of angina pectoris in the aged. In younger persons the func- 
tional angina due to neurotic or to toxic causes is the more 
frequent one. 

Symptoms. — The cardinal symptoms are an intense par- 
oxysmal pain over the heart, a sense of faintness and an agoniz- 
ing fear of death. The heart feels as if it were suddenly cramped 
or crushed and the patient will either be afraid to move or he 
will clutch at his chest as though he would grasp the heart. 
The pain is sometimes localized, more often it extends to the 
neck and goes down the left arm. In some cases the pain 
seems to involve the whole chest, back, neck and arm^ The 
face becomes pale and ashy colored, there is a cold sweat and 
in some cases there is the ''facies Hippocrates" which is seen 
just before dissolution. Death sometimes occurs during the 
attack or in the syncope following tire attack. In some cases 
there is arrhythmia or a feeble fluttering heart, in some there 
appears to be no change in the force or rhythm while in others 
there may be palpitation with increased force in the pulse. 

In some cases there is a wheezing respiration and dyspnea, 
a further evidence that the vagus is disturbed. The attack 
ends with the expulsion of gas from the stomach. The whole 
cycle lasts a few seconds, rarely minutes. In the functional 
angina pectoris the attack is not so severe and it is usually pro- 
longed, lasting several minutes. The pain does not radiate to 
the neck, there is generally arrhythmia, syncope is frequent, 
but death during an attack is rare. These attacks usually end 
with the excretion of a large quantity of urine. Hysteria is a 



ANGINA PECTORIS 1 77 

prominent factor in many of these cases. A toxic form of angina 
pectoris is brought on by excessive smoking or tea or coffee 
drinking. In this form the pains are spasmodic, lancinating 
and may come on intermittently for hours. Palpitation, 
dyspnea, nausea, syncope, occasionally trembling and profuse 
sweating are the symptoms encountered in this form of the 
disease. 

In the "angina sine dolore" there are the sudden sense of 
faintness and fear of death, with a precordial ache or distress 
but without the agonizing pain of true angina pectoris. Like 
the latter it lasts but a few seconds and is usually followed by 
eructations of gas. There is usually arrhythmia and dyspnea. 

Diagnosis. — True angina pectoris cannot be mistaken. The 
functional angina gives a causal history, the attacks are milder, 
longer and more frequent. A mistake may be made if the 
patient is seen for the first time during a severe attack of func- 
tional angina pectoris. If no causal history or history of pre- 
vious attacks is obtainable it may be necessary to wait until the 
attack is over before a definite diagnosis can be made. 

Treatment. — In the treatment of angina pectoris the most 
important indication is the immediate relief of the attack. 
In some cases the inhalation of 5 minims of nitrite of amyl 
will cause immediate subsidence of the pain. It is probable 
that in these cases there is a spasm of the coronaries producing 
myocardial ischemia and consequent weakness of the cardiac 
walls. This allows an increased influx of blood without a 
corresponding expulsion and increased tension in the cavities. 
This would substantiate two of the theories advanced to ex- 
plain the pathogenesis of the disease. In some cases vaso-dila- 
tors increase the severity of the attack and we must resort to 
chloroform inhalations, giving few drops at a time. As quick 
action is necessary during the attack, if amyl nitrite is not at 
hand, a hypodermic injection of i minim of a i per cent, 
solution of nitroglycerin should be given. If the patient has 
once had an attack he should be instructed to carry nitrite 
of amyl pearls with him and as there is usually a prodromal 
sense of uneasiness in the cardiac region before the attack, 
he should crush a pearl in a handkerchief and inhale it. The 
pearls can be obtained in silk bags which can be crushed between 
the fingers. At such times every second is precious. If 



178 PATHOLOGICAL OLD AGE 

neither amyl nitrite nor chloroform gives relief, we must give a 
hypodermic injection of 1/4 grain of morphine combined 
with i/ioo grain of atropia. If there is palpitation an ice bag 
over the heart is generally of service. 

As the attacks occurring in the aged are almost always asso- 
ciated with coronary or aortic sclerosis and cardiac degenera- 
tion, the treatment between attacks should be directed to these 
conditions. In the functional anginas whether neurotic or 
toxic, the underlying cause must receive attention. Smoking, 
tea and coffee are injurious in all cases. Excitement and 
laborious tasks, especially such as require a sudden exertion, 
must be avoided. Sudden ana powerful emotions have been 
known to bring on attacks or aggravate the disease by increas- 
ing their frequency and severity. In some cases of functional 
angina we can find no causative factor and we must eliminate 
everything that might be considered injurious, even tea and 
coffee though these had been used sparingly; we must avoid 
all physical strains, including straining at stool, and all sources 
of excitement. 

(For the treatment of coronary sclerosis, see Arterioscle- 
rosis, and for cardiac degeneration see chapter on Cardiac 
D egenerations . ) 

SENILE BRONCHITIS 

This form of bronchitis is an atrophic catarrh of the degen- 
erated mucous membrane of the air passages. It is a purely 
senile condition. 

Etiology. — It occurs most frequently in those who live in 
houses heated by hot air or where no provision is made to 
keep the air humid. They rapidly develop an atrophic state of 
the mucous membranes with diminished sensibility and less- 
ened secretion. Dust collects upon this mucous membrane 
and owing to the diminished sensitiveness, the dust does not 
create the sensory irritation necessary to produce cough which 
would dislodge it. The expired air is not expelled with suf- 
ficient force to carry off the deleterious substances with which 
the lining membrane of the bronchi is coated and they produce 
a constant irritation of the membrane with increase in the flow 
of mucus. 



SENILE BRONCHITIS 1 79 

Pathology. — There are the usual senile changes in the bron- 
chial tubes, atony and waste of the muscular fibers, atrophy 
of the mucous membrane which becomes loose and flabby 
with diminished sensitiveness and waste of the ciliated epi- 
thelium. The glands are atrophied but there is a slight flow of 
thin mucus mixed with epithelium, leucocytes and dust. The 
mucus in the finer bronchioles may be thick and tenaceous. 
The tubes are coated with dust imbedded in mucus. 

Symptoms. — The principal symptom is a morning cough by 
which a small amount of mucus is brought up, usually after 
considerable effort. The mucus is thick, dark, tenaceous and 
free from pus. It contains epithelium, leucocytes, pigment 
granules, dust, etc. The patient does not cough during the 
day unless he has made some great effort in which the lungs 
were used excessively, as in shouting or much talking, or 
if there has been excessive irritation as by inhaling irritating 
vapors, or entering a very dusty apartment. Certain forms of 
dust or vapor may be more irritating than others, as tobacco 
smoke, the vapor of roasting coffee, pollen, etc. In such case 
the cough may be paroxysmal, very severe and exhausting 
yet yielding nothing more than a drop of inspissated mucus. 

The physical signs of senile bronchitis are in evidence 
before the morning cough but not afterward. The first few 
respirations — after the patient has arisen and the level of the 
mucus has been changed — will bring out moist rales, heard best 
in the lower part of the chest near the spinal column where 
the mucus had collected by gravitation. After the mucus had 
been coughed up the chest is free from rales. Percussion may 
reveal a duller note where the mucus had accumulated. 

This form of bronchitis is differentiated from other forms 
by the scanty secretion, absence of signs after the morning 
cough, absence of temperature, absence of pain except when a 
paroxysmal cough is induced during the day, its persistence and 
its occurrence at any time of the year. In senile emphysema 
rales are heard in the back immediately upon arising but they 
are sibilant or snappy caused by the opening of the air vesicles 
which had been compressed while the patient was in the 
recumbent position. There is no cough in this condition. 

Treatment. — Senile bronchitis may be relieved by medicinal 
measures but a cure can be effected only if the cause is removed. 



l8o PATHOLOGICAL OLD AGE 

A dense humid atmosphere free from dust and vapors, and an 
equable cHmate are imperative. This can best be obtained near 
the seashore either in Florida or southern California. High 
elevations should be avoided. The activity of the mucous 
glands should be stimulated and for this purpose nothing 
equals the syrup of the hypophosphite of ammonium, given in 
dram doses every four hours. 

Menthol and eucalyptol inhalations are stimulating and 
may be used for the upper air passages. If the secretion is 
thick and tenaceous the muriate of ammonia should be given 
in 5 -grain doses three or four times a day and if there is any 
difficulty in expectoration, senega, ipecac, squills or similar 
expectorants may be tried. 

Morphine, codeine, atropine and other drugs which di- 
minish the secretions are contraindicated. Spasmodic attacks of 
coughing can generally be relieved by the bromides, preferably 
the bromide of ammonium. 

SENILE GASTRIC CATARRH 

The terms senile gastric catarrh, chronic gastric catarrh 
and chronic gastritis, when applied to the senile degeneration 
of the stomach, are misnomers as there is neither a catarrhal 
nor an inflammatory process. Ewald declares that there are 
no exclusively senile gastric or intestinal diseases. This is 
true to the extent that the symptoms of senile catarrh may 
appear in earlier life and that similar anatomical and physio- 
logical changes as occur in senility may occur as pathological 
conditions earlier. When we consider, however, that these 
pathological conditions of maturity are physiological condi- 
tions in old age and that the altered functions in old age are the 
normal functions at that period of life we must consider the 
hyperactivity, hypoactivity or perversion of these functions as 
true senile disorders. As long as the manifestations of senility 
are looked upon as symptoms of a pathological condition of 
maturity, so long will there be opposing views as to the nature, 
character and treatment of diseases that appear as changes 
from the normal senile state. The condition here described as 
senile gastric catarrh is one of these diseases. (The chronic 
gastritis which follows the acute inflammation of the stomach 
will be described with acute gastritis.) 



SENILE GASTRIC CATARRH l8l 

Etiology. — Perversion of the normal function of the senile 
stomach may occur without any apparent cause. In most cases 
it is due to overfeeding or to too frequent feeding through 
failure to recognize the diminished need of the organism for 
food and the slower gastric digestion. In some cases there 
occurs fermentation or decomposition in the stomach, especially 
if meats or eggs are taken that had been long in cold storage, 
or if beer is taken with the meals. Gastric fermentation is less 
injurious than gastric decomposition since toxins are elaborated 
in the latter process and are absorbed. Excessive amounts of 
protein may remain for many hours in the stomach and if addi- 
tional food is introduced before the residue has been disposed 
of, food will constantly be present in the stomach in various 
stages of digestion, exhausting the organ. Irritating substances 
will produce an acute catarrhal or inflammatory condition, not 
the chronic condition here described. Improperly masticated 
food may produce either the acute or the chronic condition. 

Pathology. — There are the ordinary senile changes, atony 
and waste of muscular fibers permitting a dilatation of the 
organ; thinning of the mucous membrane and atrophy of the 
glands; diminution in peptic secretion and in the amount of 
hydrochloric acid. The pyloric sphincter is sometimes hyper- 
trophied ; occasionally there is atony permitting dribbling into 
the duodenum of undigested or partly digested food that should 
have been prepared and converted in the stomach. After pro- 
longed irritation from the etiological factors mentioned, the 
mucous membrane undergoes granular degeneration and may 
disappear almost entirely. In extreme cases of senile atony the 
stomach is little more than a reservoir for food, with slight 
peristaltic power and little digestive capacity. In the latter 
case, the digestive work is done by the intestines and as long 
as they are able to carry on this work the nutrition of the 
organism will continue unimpaired. When the intestines fail 
the grave results of inanition quickly follow. 

Symptoms. — The symptoms of senile gastric catarrh are 
for the most part exaggerations of the normal senile manifesta- 
tions and coming on slowly and gradually they are not noticed 
by the individual until a pathological condition has been pro- 
duced or secondary symptoms appear. The earliest of the 
primary symptoms is anorexia. The appetite is normally 



l82 PATHOLOGICAL OLD AGE 

diminished in the aged and if the senile changes are far advanced 
the appetite may fail altogether. There is a sense of fulness in 
the stomach lasting sometimes for hours after a meal. Flatu- 
lence and eructation of gas are frequent accompaniments of this 
condition and if the stomach is dilated with gas, it may press 
upward upon the diaphragm, disturbing the heart action and 
producing the syndrome called gastric asthma. If this occurs 
there is palpitation or arrhythmia of the heart, dyspnea, and 
if severe there may be vertigo, syncope and even collapse. 
The cases of sudden or rapid death from acute indigestion are 
cases where the rapid and excessive formation of gas in a dilated 
stomach caused sudden disturbance of the heart action with 
consequent paralysis of the heart or interference with the cere- 
bral circulation. Vomiting is rare except when the stomach is 
overloaded with food and even then some extraordinary irrita- 
tion is required to arouse a sufficiently powerful reflex action 
to cause vomiting. 

Cabot says ''any type of dyspepsia, any sort of genuine 
gastric trouble occurring in a person over forty years, who has 
never had any such trouble before, is strongly suggestive of 
cancer." After the age of sixty senile gastric catarrh occurs 
far more frequently than malignant disease, and Cabot's state- 
ment should apply only to the period between forty and sixty. 
It is sometimes impossible to make a positive early diagnosis 
of carcinoma of the stomach, as the earliest symptoms resemble 
the early symptoms of senile gastric catarrh, there being in 
both gastric dilatation and hypoacidity. As vomiting is rare 
in the senile form of dilatation which is due to atony and it is 
an early symptom of dilatation due to obstruction of the py- 
lorus, this may serve to differentiate cancer from senile catarrh. 
If vomiting does occur in senile catarrh it is due to excessive or 
improper food and the substance brought up is food in various 
stages of digestion but there is little mucus and no blood. The 
vomited matter in cancer almost always contains mucus and 
often blood. The later symptoms of carcinoma are sufficiently 
distinctive to prevent an error in diagnosis. The absence of 
pain in senile gastric catarrh is a strong diagnostic point for the 
elimination of ulcer, cancer and acute and chronic gastritis. 
Senile gastric catarrh can be differentiated from chronic gastric 
catarrh which is secondary to the acute form by the absence or 



SENILE GASTRIC CATARRH 1 83 

small quantity of mucus which is brought up, while in the 
chronic or secondary form a large quantity of mucus is vomited. 
There is also a history in the case of the secondary form which 
determines the underlying cause. 

Treatment. — The treatment of senile gastric catarrh com- 
prises dietary and hygienic, medical and mechanical measures. 
The first indication is to clean out the stomach. Some authori- 
ties say lavage is easily accomplished in the aged owing to 
lessened sensibility of the pharynx, esophagus and stomach. 
On the other hand spasm of the muscles of deglutition and of 
the glottis is easily induced and a fatal asphyxia may result. 
To prevent spasm a spray containing 2 per cent, of cocaine 
should be used in the throat and a stomach tube of small caliber 
should be employed. A 3 per cent, solution of boracic acid 
can be used to wash out the stomach. After lavage the 
stomach should be given a rest for two hours, after which 
give 1/50 grain of strychnine or 5 minims of the tincture of 
nux vomica combined with a dram of compound tincture of 
gentian or Colombo and the same amount of water. Food 
can be given ten or fifteen minutes later. Excellent results 
have followed the foregoing plan of treatment. Lavage can 
be employed every day for three or four days, then every second 
or third day. The food should be concentrated containing 
little meat and little cellulose. Predigested foods are recom- 
mended but most of the foods of this character contain a large 
percentage of alcohol. The patient may take meat juice, soft 
boiled eggs, cream, malted or evaporated milk, toasted bread, 
well-boiled vegetables containing little cellulose, etc. Water 
acidulated with hydrochloric acid should be taken during the 
meal. Ewald recommends that the water should be as strongly 
acid as the patient can swallow without difficulty and it should 
be taken after meals. As liquid introduced into the stomach 
filled with food does not mix with the food but passes off into 
the duodenum, the advice to take the acidulated water after 
meals is irrational. Pepsin should be given with or immediately 
following the meal. If there is much flatulence charcoal in 5- 
grain doses should be added to the pepsin. Incidental measures 
are the simple bitters like gentian, Colombo, cinchona and 
quassia in dram doses of the tincture or 5 grains of orexine for the 
anorexia, and nux vomica as a tonic and a glass of hot water 



184 PATHOLOGICAL OLD AGE 

containing a teaspoonful of common salt or phosphate of soda 
upon arising. This washes away the mucus with which the 
inner surface of the stomach becomes coated during the night, 
and it also acts as a mild laxative. 

It is sometimes possible to relieve a gastric catarrh by 
these means alone if the stomach is then given complete rest 
for the day and the saline hot water is repeated at bedtime. 
The diet must thereafter be selected to give the stomach as 
little work as possible and to produce as little gas as possible. 
We m.ust warn again against meat, fish and eggs that have been 
kept long in cold storage or have been preserved with chemicals. 
Nausea and vomiting are rare and if vomiting occurs it is 
nature's method of getting rid of offending material. If 
there is nausea and the stomach is filled with food, 5 grains of 
pepsin should be given to aid digestion and 1/4 -grain aloin to 
stimulate stomach peristalsis. If the nausea occurs when 
the stomach is empty it may be due to an accumulation of mucus 
in the stomach. Occasionally nausea upon arising will be 
caused by the accumulation of mucus in the pharynx. In 
either case hot water containing a small quantity of salt should 
be taken to dislodge the mucus. A persistent nausea when 
the stomach is empty is rapidly relieved by 1/12 grain of cocaine 
hydrochlorate. This will also relieve gastrodynia. Pyrosis 
is infrequent in the aged but if it does occur 5 grains of bismuth 
subnitrate combined with either 1/12 grain of cocaine or 
morphine should be used. If hyperacidity occurs it is due to 
acetic, butyric and lactic acids, all decomposition products. 
Alkalies which cure hyperacidity in matiirity are contra- 
indicated in the aged and we must resort to antifermentives 
like salicylic acid, boracicacid, creosote, charcoal, etc., to prevent 
further fermentation and decomposition. 

The most important hygienic measures are freedom from 
worry, mild exercise and regulation of the bowels. A temporary 
constipation may undo in two days, all the good obtained by 
several weeks' treatment. Salines should be given either in 
an occasional large dose or in small doses for several days. 
They should not be given in habitual constipation. The 
ordinary senile constipation should be treated as indicated in 
the chapter on Senile Degeneration of the Intestines. 



GASTRIC NEUROSES 1 85 

GASTRIC NEUROSES 

Gastric neuroses occur rather frequently in the aged. 

While some of these diseases are rare in the aged and others are apparently- 
associated with hysteria or neurasthenia, they are all placed in the second group 
of diseases upon the assumption that most of the neuroses occurring in the aged 
are due to the senile change in the nervous system, to arteriosclerosis or change in 
the stomach or its secretions. 

Pneumatosis or distention of the stomach with gas which 
the stomach cannot dispel owing to atonicity of the walls is 
of frequent occurrence. It is one of the causes of gastric asthma, 
the dilated and distended stomach pressing upward upon the 
diaphragm and thus upon the heart. The treatment of this 
condition is the treatment of gastric atonicity. If rapid 
eructation of gas is necessary lo to 20 minims of oil of turpen- 
tine should be given and pressure applied over the stomach. 
Turpentine stupes over the abdomen will give temporary relief. 
In some cases 5 grains of willow charcoal and 5 grains of sodium 
bicarbonate will be more effectual than the turpentine. To 
prevent excessive fermentation dilute hydrochloric acid should 
be given with every meal. Nervous eructations are infrequent 
in the aged. They may occur when food is taken in too rapid 
intervals. 

Pyrosis or heartburn is usually due to gastric dilatation 
with hyperacidity. Hyperacidity being, however, rare in the 
aged, pyrosis is also rare. When it does occur, the underlying 
condition must be treated. For immediate relief we can give 
1/8 grain of cocaine. 

Gr astro spasm either at the cardiac or pyloric orifice, is oc- 
casionally met with in old age. It sometimes follows a cold 
drink, a strong alcoholic beverage, sharply spiced food or strong 
emotion. Pyloric spasm may follow an excessive meal or food 
improperly or insufficiently masticated. In some cases no 
cause can be discovered. The treatment depends upon the 
cause, if discoverable. In other cases abstinence from food 
wiU frequently give relief. The bromides are useful in this 
condition. 

Relaxation of the pylorus occurs occasionally from atony of 
the pyloric sphincter. (This is described under the Senile 
Degeneration of the Stomach.) Other causes are shock or 



1 86 PATHOLOGICAL OLD AGE 

strong sudden emotion such as fright, etc. A persistent relaxation 
may be suspected when there is a hentery containing meat fibers. 
The treatment depends upon the cause. Nothing can be done 
for the temporary condition due to shock, fright or similar 
causes. Supermotility does not occur in the aged. 

Secretory neuroses are infrequent in the aged. Hyperchlor- 
hydria and gastrosuccorrhea are extremely rare and hypochlor- 
hydria as part of an achylia gastrica is a normal condition in the 
aged, due to atrophy of the secreting glands. This is not a 
neurosis but a true senile degeneration for which nothing can 
be done. Where it exists we can supply the deficiency 
artificially. 

Sensatory neuroses occur rather frequently, the most promi- 
nent being anorexia. 

Diminished appetite is natural in the aged. Diminished 
activity causes less waste and less expenditure of energy, and 
less food is consequently required. Other factors which tend 
to diminish the appetite in the aged are lessened salivary secre- 
tion, dysphagia, and some change in the taste bulbs. Nothing 
need be done for this but if there is complete anorexia, the 
appetite must be stimulated by means of simple bitters. Orex- 
ine is especially useful in this condition. It is given in lo-grain 
doses about an hour before meals. 

Bulimia does not occur in the aged except as a symptom of 
diabetes, and occasionally during convalescence from pro- 
longed illness. It requires no treatment. The elixir of the 
valerianate of ammonia has been found to diminish the appetite 
but it is rarely necessary to give it. 

Parorexia or perverted appetite occurs occasionally where 
the taste for ordinary foods is lost. This is generally due to 
gustatory perversion, and manifests itself in a malacia, the 
patient craving spiced, acid or acrid foods. The craving for 
indigestible substances such as occurs in hysteria does not 
occur in the aged unless associated with hysteria, dementia or 
other psychosis. The painful gastric neuroses are rare in the 
aged. 

Hyperesthesia may occur during neurasthenia or after a 
shock, fright or other strong emotion but it does not last longer 
than a few hours. Suggestion or autosuggestion may, however, 
cause its reappearance and from this cause it may become per- 



GASTRIC NEUROSES 1 87 

manent. In this as in other painful neuroses psychic measures 
will often avail while drugs will be useless. 

Gastralgia or gastrodynia is another painful neurosis which 
may be due to suggestion. It is generally associated with 
neurasthenia, the attacks being most severe w^hen the indi- 
vidual is most depressed. The pain comes on independently 
of food and in some cases taking food gives relief. Gastralgia 
resembles a colic, moderate pressure giving relief while deep 
pressure will uncover a point of tenderness. Hepatic colic is 
more painful and the tender point is usually to the right of the 
sternum and umbilicus; intestinal colic is more diffuse and not 
over the stomach; renal colic has also a pathognomonic site 
between the kidney and the bladder. Cancer and ulcer are 
readily differentiated from simple gastralgia. Gastric ulcer is 
rare in old age and it can be distinguished by the presence 
of a hyperchlorhydria. In cancer the history, cachexia, vomit- 
ing, localized pain and later the presence of a growth ought to 
differentiate it from gastrodynia. Intercostal neuralgia is 
more severe, is higher up and more localized. 

In the treatment of the painful senile neuroses, psychic 
measures will often avail. When drugs are required bromide 
of sodium or strontium should be used and in an emergency for 
the more rapid relief of pain w^e can use cocaine or eucain. The 
narcotics should not be used. Acidulated w^aters are generally 
weU borne. Regulation of the diet will in some cases com- 
pletely cure a neurosis, and in some cases a day's starvation 
wiU cause the symptoms to disappear. 

Esophageal Neuroses. — Spasm of the esophagus occurs 
occasionally in the aged either as part of a general neurosis, 
such as hysteria or as the result of local irritation as w^hen a 
hard substance is swallowed. In some cases there is a pro- 
longed contraction of the esophagus, food failing to pass a cer- 
tain point for several minutes or hours, then passing without 
difficulty. In some cases certain articles of food, solids or 
liquids cause spasm. As the underlying cause can seldom be 
discovered, the treatment must be symptomatic, substances 
causing spasm must be avoided and bromides should be given. 
Galvanism, faradization, or fine rapid vibration sometimes 
gives relief. Psychic measures are often effective. The patient 
may have a spasm through fear and if the fear is allayed the 



155 PATHOLOGICAL OLD AGE 

spasm will not occur. In one case in which swallowing water 
produced a spasm, a glass of water slightly flavored and given 
by the physician as medicine was swallowed without difficulty. 

Globus hystericus, anesthesia and hypesthesia are usually 
hysterical phenomena and need no other treatment than that 
for the underlying condition. 

Intestinal Neuroses. — Intestinal neuralgia is extremely rare 
and is supposed to be due to arteriosclerosis of the abdominal 
aorta or the mesenteric artery. Colic is almost invariably due 
to the presence of an irritant or peristaltic stimulant. Exces- 
sive motility does not occur except when due to a stimulant and 
atony is almost always due to the natural senile degenerative 
changes in the walls. The treatment depends upon the cause. 

CHOLELITHIASIS 

Gall-stone formation is the most frequent disease of the 
liver and its adnexa in old age, and autopsies frequently reveal 
gall-stones in the gall-bladder, though often they gave no 
indication of their presence during life. 

Etiology. — The frequent finding of gall-stones in the aged 
at autopsy, which gave no symptoms during life, would tend to 
exclude infection as the principal etiological factor and would 
point to a change in the character of the hepatic secretion or 
to diminished expulsive activity of the gall-bladder, probably 
both, causing an increase in the proportion of cholestein, some- 
times a deposit of calcium salts, and stasis. The most prolific 
causes in earlier life, infection and inflammation of the gall- 
bladder may prevail in old age, but infection is rare, while 
inflammation is more often resultant than causative. In Mac- 
Carty's statistics nearly 70 per cent, of cases of acute chole- 
cystitis had gall-stones and 93 per cent, of chronic cholecystitis 
cases were associated with gall-stones. As acute gastrointes- 
tinal catarrh is infrequent in senile cases and chronic atrophic 
catarrh has not the tendency to extend through the common 
duct to the gall-bladder this cause of cholecystitis is rare, and 
we can assume that if cholecystitis is present it is due in most 
cases to the irritation produced by the concretions. 

Symptoms. — As has been stated above, many cases give no 
symptoms. In some cases the only suspicious symptoms are 



CHOLELITHIASIS 1 89 

those, connected with deficient bile supply; clayey, foul-smelling 
stools, perhaps containing fat globules, a ^^ellowish furred tongue, 
bad breath and sallowness. If in these cases pressure is made 
over the region of the gall-bladder and tenderness is elicited there 
is a mild cholecystitis present probably due to gall-stones. There 
is no pathognomonic symptom of gall-stones except their pres- 
ence in the stools. The hepatic colic is caused by the spas- 
modic contraction of the unstriped muscle fibers of the gall- 
bladder, in the effort to expel and propel the contents, which may 
be pus, mucus or blood as well as bile concretions. In senile 
cases, however, if these morbid contents are present, they are due 
in almost every case, to infection, occurring especially during 
typhoid fever. The symptoms resolve themselves into the 
symptoms of cholecystitis, obstruction of the ducts and colic. 
In mild cholecystitis there is generally a dull ache, not severe 
enough to produce actual suffering but quite pronounced at 
times, and often we may elicit pain upon pressure over the 
region of the gall-bladder, and in the back about an inch to the 
right of the eleventh dorsal vertebra. In pronounced inflam- 
mation the pain is severe and there is fever, either intermittent 
if due to bacterial infection, or a steady increased temperatiure 
if due to local non-bacterial irritation. In rare cases in the 
aged a cholecystitis exists without cholelithiasis and in these 
cases the contraction colic is shorter and milder than when 
gall-stones are present. Jaundice is sometimes observed, and 
bile is occasionally found in the urine. 

When gall-stones lodge in the common duct they give rise 
to symptoms of biliary obstruction. (See Biliary Obstruction, 
page 329.) There is then deficiency of bile supply to the bowels, 
jaundice and colic. The jaundice is variable, being sHght in 
some cases and severe in others, always deepening after a colic 
paroxysm. With this form of jaundice w^e find bile in the urine 
and none in the feces. 

The colic which is the most constant and characteristic 
attendant of gall-stones occurs in paroxysms which are fairly 
regular w^hen the duct is involved, but occurring at irregular 
intervals when the gall-bladder alone is affected. In senile 
cases the attacks are not as severe as in earlier life nor are the 
chiUs, sweating and fever accompanying the pain as pronounced. 
The pain occurs as a sudden agonizing neuralgia in the right 



IQO PATHOLOGICAL OLD AGE 

hypochondrium, radiating toward the right shoiilder. If the 
colic originates in the common duct the pain begins in the 
epigastric region and radiates backward and not upward. In 
this case the remittent jaundice distinguishes it from other 
abdominal colics. The diagnosis of cholelithiasis is rather 
difficult in senile cases, owing to the mildness and irregularity 
of the symptoms. Old cases may give the characteristic 
symptoms of hepatic colic but usually the rigor, chill and fever 
are not severe, there is no vomiting and but little sweating, 
while jaundice is rare. In some cases there are occasional 
sharp pangs in the epigastrium and pain can be elicited on pres- 
sure over the gall-bladder. More often there is a persistent 
dull ache in the epigastrium with the symptoms of deficient 
biliary supply to the bowels. In these cases there may be 
paroxysms of pain marking the passage of a calculus through 
the duct and then there is intense mental and physical depres- 
sion similar to shock. The diagnosis has often been confirmed 
by radiography. 

Complications. — The number or size of the concretions may 
fill the gall-bladder producing inflammation and ulceration. 
As a remote result rupture of the organ may ensue, followed by 
rapidly fatal shock or peritonitis. Other complications are 
biliary fistulae, intestinal obstruction by gall-stones, adhesions 
of the organ, cancer. 

Treatment. — During the attack relief from pain is the only 
indication and for that purpose there is nothing that will take 
the place of a hypodermic injection of morphine combined with 
atropine, giving 1/4 grain of morphine as an analgesic and i/ioo 
grain of atropine to counteract the effect of the morphine upon 
the respiratory centers and to cause relaxation of the muscular 
fibers. Chloroformx inhalation will also give immediate relief 
but is dangerous if there is arteriosclerosis. Olive oil in from 
2- to 6 -ounce doses has been recommended but it is doubtful 
of having any other effect except that of aiding in the expulsion 
of those calculi that reach the duodenum. Chloral hydrate is 
excellent in younger individuals but it is dangerous in the aged. 

The treatment in the intervals between attacks depends 
upon the severity and frequency, the amount of distress and the 
general condition of the patient between the attacks. If the 
symptoms are mild and the attacks are infrequent operation is 



SENILE METRITIS I9I 

unnecessary. If there is a fatty heart, myocarditis or cardiac 
dilatation, nothing but the certainty of death without opera- 
tion will justify surgical interference. If the attacks are 
frequent and severe or if there is an infective cholecystitis, 
operation becomes necessary, sometimes even imperative. In 
all other cases, however, medicinal measures should be tried 
before resorting to cholecystectomy or cholecystostomy. There 
is no known method of resolving gall-stones in situ. Numerous 
drugs have been recommended for this purpose, those most 
frequently employed being the sodium choleate, sodium oleate, 
sodium salicylate, sodium succinate and iron succinate, olive oil 
and oil of turpentine. The salts have the property of stimulat- 
ing the flow of bile and making it more fluid but it is doubtful 
whether they have any effect upon the concretions already 
formed. By increasing the fluidity of the secretion, further 
formation of calculi is prevented and this often suffices to pre- 
vent a recurrence of an attack. The sodium choleate in 5 -grain 
doses twice or three times a day has this effect upon the bile 
and also supplies the deficiency of the duodenal secretion. 
The sodium succinate acts more powerfully upon the liver 
and upon the secretion but has no effect upon foods in the 
intestinal tract. Drug treatment must be continued for months 
or years, as their effect is only temporary. If the attacks 
continue during the drug treatment with undiminished severity 
or reappear after discontinuance of prolonged drug treatment, 
operative meastures become necessary. The form of operation, 
whether cholecystectomy or cholecystostomy, will depend upon 
the exploratory findings and the surgeon's preference. 

SENILE METRITIS 

Metritis originating after the menopause and not associated 
with a growth nor produced by traumatism is rare. 

Etiology. — Most of the reported cases were due to the 
retention of mucus through vaginal atresia or cervical occlusion, 
with subsequent septic infection. A hemorrhagic form, which 
is, however, extremely rare, is supposed to be due to a cardiac 
lesion with consequent venous stasis. Various predisposing 
causes have been suggested but the cause given for the purulent 
form is sufficiently potent to explain every case of this form. 



192 PATHOLOGICAL OLD AGE 

It occasionally occurs soon after the menopause, more fre 
quently a few years later. 

Symptoms. — The earliest and most pronoimced symptom is 
a purulent or sanguinous discharge having a most offensive 
odor. In some cases the discharge is scanty, in others copious; 
sometimes intermittent, at other times continuous. There 
is usually little pain; occasionally a colicky pain in the uterus 
precedes a sudden gush of the discharge. In some cases there 
is a rapidly progressive cachexia with emaciation, sallowness, 
and gastric disorders. In making a digital examination partial 
atresia of the vagina and a vaginitis are usually found. The 
cervix is soft, apparently swollen and painful to the touch. 
Examination with the speculum is frequently impossible owing 
to the constriction and the inflamed condition of the vagina. 
The fetid odor and the cachexia cause this disease to be generally 
mistaken for uterine cancer and cases have been operated upon 
which in their clinical manifestations could not be distinguished 
from uterine cancer. A curettage scraping should be examined 
in every case of doubt. The determination of the actual 
pathological condition present is of the utmost importance, 
the life of the patient depending upon the treatment, which is 
entirely different in the two diseases. If the curette scraping 
does not clear up the diagnosis or if curettage is impracticable 
it is better to await the result of treatment for metritis than to 
conclude that we are dealing with a uterine cancer and proceed 
to perform a hysterectomy. The disease is grave and while 
most cases recover under appropriate treatment, there is 
always danger of spreading local and general infection, and of 
exhaustion. 

Treatment. — The primary indication is to clean out the 
uterus. The cervix must be dilated and the contents of the 
uterine cavity should be washed out with a mild solution of 
permanganate of potash or sterile water. This may be followed 
by a solution of peroxide of hydrogen. Curettage with a 
sharp curette is dangerous on account of the thin and degen- 
erated walls, and with a blunt instrument it is useless. Only 
the necessity of arriving at a correct diagnosis justifies the use 
of the sharp curette in making a scraping for examination. 
After the cavity has been emptied and cleaned it should be 
packed with iodoform gauze. This treatment should be 



CEREBR,A.L AXEMLA. 1 93 

continued for several days after which it will suffice to pack 
the vagina alone until the discharge ceases. The constitutional 
treatment consists of absolute rest in bed, tonics and the usual 
treatment for exhaustion. The same treatment is indicated in 
the hemorrhagic form but curettage is positively contraindicated. 

CEREBRAL ANEMIA 

Cerebral anemia is frequently found in the aged but its 
advent is so slow that the patient accommodates himself to 
the symptoms and does not notice them or ascribes them to the 
result of ageing. 

Etiology. — It is generally due to sclerosis of the cerebral 
arteries with weak heart and especially with aortic stenosis. 

Symptoms. — When due to cerebral arteriosclerosis there 
will be the symptoms of this disease, vertigo, dizziness, tinnitus, 
weakened memor^^ and neuralgic or prolonged headaches with 
drowsiness and a feehng of emptiness in the head. The patient 
win have an instinctive desire to lie down and the symptoms 
will subside in the recumbent position. In cerebral arterio- 
sclerosis without anemia change of position does not reheve 
these symptoms. Cerebral anemia due to other causes is readily 
differentiated from this form which is peculiar to the aged. 

Treatment. — The treatment is the same as for cerebral 
arteriosclerosis. The hypodermic use of sterile solutions of 
arsenic and iron or the administration of hemoglobin in 15- 
grain doses three times a day may improve the character of 
the blood. The symptoms usually increase, however, and syn- 
cope may occur after any excitement or even while but taking 
a hot foot bath. The nitrites and cardiac stimulants are then 
indicated. 

ALTERNATING CEREBRAL ANEMIA AND 
HYPEREMIA 

This is a disturbance of the cerebral circulation in which 
there is a progressively increasing anemic condition when the 
patient is sitting or standing and a progressively increasing 
hyperemic condition when the patient is lying down. This 
occurs normally in a mild degree, prolonged standing causing a 
13 



194 PATHOLOGICAL OLD AGE 

mild cerebral anemia with consequent drowsiness and sleep. 
Some cases of anemia develop, however, a pronounced hyper- 
emia in the recumbent position, which is nothing more than an 
exaggeration of what occurs normally. It is probably due to 
some defect in the vasomotor regulation and to atheromatous 
but not calcareous cerebral vessels. 

Symptoms. — The patient awakes with a dull frontal head- 
ache and mental confusion, flushed face, injected conjunctivae 
and the concomitants of cerebral hyperemia. These gradu- 
ally pass away after arising, sometimes within a few minutes, 
sometimes in an hour or two. There is then no symptom of 
cerebral disturbance for several hours when the symptoms of 
cerebral anemia appear. The face becomes pale, lips and ears 
are slightly blanched, the patient feels tired and drowsy and 
there may be vertigo, tinnitus, headache, and unless he lies 
down, there will be syncope. 

Upon lying down these symptoms gradually disappear and 
are followed by the symptoms of cerebral hyperemia. There 
is a gradually increasing frontal headache, a feeling of heavi- 
ness, mental dulness and an instinctive feeling that he will 
be relieved upon arising. If he falls asleep, he will become 
restless after a few hours, snore, moan and will awake with the 
symptoms of cerebral hyperemia, thus completing the cycle. 

Treatment. — As there are two opposing phases of this dis- 
ease, whatever will benefit the one will be detrimental to the 
other. The hyperemic is the more serious phase on account of 
the distress and possible secondary effects. The anemia can 
be relieved temporarily by the use of the nitrites, giving 
I minim of a i per cent, solution of nitroglycerin when the symp- 
toms appear. The patient will instinctively want to lie down 
and this affords speedy relief. For the hyperemia we need 
rapidly acting vasoconstrictors like ergot, or digitalin or stro- 
phanthin hypodermically. The drug must be stopped as soon 
as the effect is produced. The patient must lie with the head 
elevated and upon arising he should take a hot foot bath. 
Drugs used for the relief of symptoms must be rapidly acting, 
the effect passing away in a few hours. There is no way of 
restoring the impaired vasomotor centers. Strychnine arsen- 
ate has been of service in some cases. It is given in doses of 
i/ioo grain three times a day. 



CEREBRAL SOFTENING I95 



CEREBRAL SOFTENING 



Cerebral softening is a degeneration of brain substance due 
to sudden or rapid deprivation of nutrition. It differs from 
the normal senile degeneration which involves the whole brain, 
proceeds slowly and has but a diminished blood supply, while 
in cerebral softening the blood supply is completely with- 
drawn from a part. It occiu-s in two forms — the usual senile 
thrombotic form which comes on gradually and the embolic 
form which comes on suddenly. While there are other causes 
than thrombosis and embolism every case can be placed under 
one of these two heads of gradual or sudden form of cerebral 
softening. 

Etiology. — The most frequent cause of cerebral softening 
in the aged is a thrombus in an atheromatous vessel of the 
circle of Willis or in one of the branch vessels. It may also 
occur in cerebral arteriosclerosis in which the lumen of a vessel 
is obliterated. An embolus, which is the most frequent cause 
of cerebral softening in earlier life does not occur as frequently 
in the aged. Such accidental causes as syphilis, infectious 
diseases, anemia, leukemia, etc., which may cause endocarditis 
with vegetations and consequent embolus, or carbonic-acid 
poisoning, burns, tumors and other local conditions which may 
cause thrombosis, are rare in the aged. 

Pathology. — The first change is an anemia of the tissue sup- 
plied by the vessel which is blocked. In from three to four days 
this tissue begins to soften into a creamy or pale semifluid 
mass. This exhibits under the microscope ddbris of neuroglia, 
altered cells and fibers, a mass of leucocytes attacking the de- 
generated tissue and disposing of it by phagocytosis. The 
destroyed area becomes later filled with fibrous tissue. 

Symptoms. — The two forms of cerebral softening differ 
markedly in their onset but after the brain substance has 
begun to degenerate they are aHke. 

Thrombotic cerebral softening comes on gradually. For 
weeks perhaps there were symptoms of cerebral atheroma, 
with headache, vertigo, nausea and occasional confusion of 
ideas. As the nutrition of the part becomes diminished there 
are symptoms of impaired functions. Numbness in one hand 
and diminishing strength with gradual loss of sensation and 



196 PATHOLOGICAL OLD AGE 

power set in. The face becomes paralyzed on the same side 
and mental confusion becomes more marked. With complete 
closure of the vessel the patient becomes unconscious and the 
whole side is paralyzed. When the patient recovers from the 
unconsciousness, there is mental confusion, motor paralysis 
and in some cases aphasia. In a mild case the patient may not 
lapse into unconsciousness but the other symptoms will 
appear. 

Embolic cerebral softening comes on suddenly like apoplexy 
from which it is sometimes difficult to distinguish. In some 
cases there are no premonitory symptoms. The patient 
suddenly becomes unconscious and upon awaking we find 
hemiplegia, mental confusion and sometimes aphasia. In 
another class of cases the attack begins in an agony of fear, 
followed rapidly by mental confusion, aphasia, clonic spasms 
of one or both extremities, rapid loss of motion and sensation 
on one side, followed by unconsciousness lasting fifteen to 
twenty minutes. Upon awaking there is hemiplegia and 
aphasia with some mental confusion. Such attacks may occur 
several times during the following two or three days. Mild 
cases in which a small branch alone is involved may present 
the symptoms of thrombosis but the symptoms come on 
more rapidly. 

Blocking of particular vessels gives pathognomonic symp- 
toms. If a vessel on the left side is blocked, aphasia is produced. 
The anterior cerebral vessels are rarely attacked and they give 
ill-defined symptoms, as collateral circulation is speedily es- 
tablished. There will be mental confusion and monoplegia of 
the opposite side, which soon disappears when circulation is 
restored through the collateral branches. Blocking of the 
middle cerebral artery produces hemiplegia and hemianesthesia. 
The branches produce various monoplegias and those on the 
left side produce in addition various forms of aphasia. The 
blocking of the posterior cerebral artery produces hemianopsia, 
hemiplegia and sometimes hemianesthesia. That of the basilar 
artery produces clonic spasms, contracted pupils, spasm of 
muscles of deglutition and hemiplegia. In complete obstruction 
we find paralysis of both sides with symptoms of bulbar paralysis. 
Blocking of a vertebral artery produces symptoms of acute 
bulbar paralysis. 



CEREBRAL SOFTENING 1 97 

The unconsciousness which ushers in the attack is seldom 
as deep as coma and is of short duration. The paralysis is 
not complete and sometimes disappears within a few days, in 
other cases it persists through life. In the thrombotic form 
there are occasional mild apoplectiform attacks, each attack 
leaving the patient w^orse than before. Mental impairment is 
marked and in some cases there is a rapid progressive dementia. 
The aphasia is usually permanent. Mental and physical 
symptoms exhibit at times marked variations, the mind being 
sometimes quite clear while within a few hours there would 
be mental confusion with loss of memory. In the same manner 
the paralysis, aphasia, coordinating power, etc., may change 
within a few hours. 

Diagnosis. — The differential diagnosis between cerebral em- 
bolus and thrombus depends upon the advent, the former being 
sudden, the latter gradual and generally with a preceding 
history of cerebral arteriosclerosis. In apoplexy the face is 
congested, the coma is complete and lasts longer than the 
unconsciousness of embolism, there is stertor, and the pulse 
is full and slow. In embolism there is generally a history of 
rheumatism or endocarditis and it comes on earlier in life 
than apoplexy. 

Tumor of the brain may produce symptoms resembling 
thrombus. There are, however, no previous symptoms of 
arteriosclerosis. The advent is very slow, headache is persist- 
ent and any slight excitement will aggravate the latter and 
may produce spasms or luiconsciousness. The symptoms are 
those of cerebral compression, namely, epileptiform convulsions, 
choked disc, facial paralysis, locaHzed pain, etc. 

Cerebral abscess generally has a history of injury or disease 
of the middle ear with septic symptoms. 

In normal senile degeneration there is a gradual failing of 
the mental powers but there is no history of unconsciousness, 
paralysis or aphasia. 

Prognosis. — The prognosis of cerebral softening is bad. 
While life may be prolonged for years in mild cases, an embolus 
in a main artery may cause rapid and extensive degeneration 
and death in a few days. The same conditions which lead to 
the formation of one embolus or thrombus will lead to the 



198 PATHOLOGICAL OLD AGE 

formation of others and several attacks usually destroy life. 
Mental impairment leads to dementia. 

Treatment. — The treatment is unsatisfactory as the same 
treatment which in one case apparently helps may have the 
opposite effect in another. The first indication is to maintain 
the strength of the heart by means of rapidly acting cardiac 
stimulants, preferably the hypodermic use of camphor and 
ether. Ammonia inhalation should be tried during the coma. 
After the first shock is past and the patient emerges from the 
coma, the further treatment depends upon his condition. 
If there is much irritability and mental confusion he must be 
kept quiet by narcotics. Cerebral excitement must be avoided 
but the treatment sometimes advocated in cerebral embolus 
and thrombus, which is to treat the case as one of cerebial 
apoplexy, is wrong. In apoplexy there is extravasation of 
blood with cerebral hyperemia and compression and the meas- 
ures employed are to diminish the flow of blood to the brain. 
In embolus and thrombus we have the opposite condition. 
There is cerebral anemia beyond the point of occlusion, there 
is no compression, the face is UvSually pale and the pupils are 
unaffected. The first symptoms of apoplexy, embolus and 
thrombus are due to shock and we must look after the heart. 
After this, however, recovery from thrombus depends upon the 
rapid establishment of collateral circulation and for this purpose 
a full supply of blood to the brain is necessary. In these 
cases powerful cardiac stimulants are indicated. We must 
be certain of our diagnosis, however, for if used in apoplexy 
they may produce fatal results. The later treatment is 
symptomatic, electricity, massage and passive motion to over- 
come the paralysis, and phosphorus for the mental impairment. 

CEREBRAL HEMORRHAGE 

The frequency of apoplexy in the fifth, sixth and seventh 
decades of life, its sudden attack and the profound impression 
upon the whole organism, mentally and physically, make it 
perhaps the most readily recognized disease of old age. The 
essential lesion is the rupture of a miliary aneurysm or of an 
artery at a point where it has been weakened by the athero- 
matous process. The break generally occurs in some part of 



CEREBRAL HEMORRHAGE 1 99 

the circle of Willis although it may occur in any artery or 
arteriole of the brain. 

Etiology. — Any cause that produces arterial degeneration 
will also act as a predisposing cause of apoplexy. The most 
prominent of these causes aside from senile involution are alco- 
hol, lead, mercury, syphilis, nephritis, gout, anemia, leukemia, 
and purpura. The exciting cause is usually some sudden strain 
which increases the blood pressure, some intense mental excite- 
ment, shock, alcoholic stimulation or other cause that would 
produce cerebral hyperemia. In many cases a hea\^ meal 
preceded the attack. 

Pathology. — The essential lesion in cerebral hemorrhage is 
a ruptured vessel, one or more miliary aneuj^^sms or an athero- 
matous artery. The grave, often rapidly fatal, attacks that 
occur in senile cases are usually due to the latter cause. The 
clot from a miliary aneurysm is small, while from a larger 
vessel it may be the size of a hen's egg. The nerve fibers that 
are compressed become sclerosed and degenerated. If recovery 
occurs the clot is not reabsorbed but breaks down and contains 
fatty granules, pigment and broken-down brain matter. 

Symptoms. — Premonitory symptoms are rare and occur 
only if the exciting cause prevails for a long time or if there are 
exciting causes not sufficiently pronounced to cause rupture. 
In such cases there are usually headache, vertigo, thick speech 
and tinghng in one hand or foot. Occasionally there is some 
impairment of the special senses, a feeling of weight or heaviness 
and intense mental depression. There is generally a momentary 
prodromal stage with terror, vertigo, weakness and numbness 
on the affected side, the patient tries to drag himself to a seat 
or comer, then falls insensible in a heap. The coma is com- 
plete, the face is red or cyanosed, the breathing stertorous, the 
pulse strong, full and slow, the sphincters are paralyzed per- 
mitting evacuation of the bladder and intestines. Hemiplegia 
invariably results, in rare cases there is a spasm or convulsion. 
The severity of the disease is determined by the severity of the 
coma and the extent of the hemiplegia. In a mild attack there 
is stupor from which the patient can be momentarily roused 
and from which he awakes in a few hours, his mind confused with 
perhaps some aphasia but able to swallow. In this case the arm 
and leg may be completely paralyzed but the facial and hypo- 



200 PATHOLOGICAL OLD AGE 

glossal nerves are but slightly affected. It is hardly necessary 
to take up the localizing symptoms which would determine the 
exact location of the rupture and extravasation of blood. If the 
hemorrhage is into the medulla the cranial nerves are affected and 
death from interference with respiration and heart action results. 
Hemorrhage into a lateral ventricle generally produces rigidity 
of the opposite side, convulsions and death. In mild cases the 
coma clears up after a few hours leaving some mental confusion, 
aphasia, headache, vertigo, occasionally some sensory impair- 
ment. The paralysis also frequently clears up slowly, but the 
affected parts rarely fully regain their power. In severe cases 
it may take two or three days before the mind is sufficiently 
clear to respond to questions and even then there may be so 
much mental confusion that the patient cannot answer intelli- 
gently. Repeated gaping is an indication that the patient is 
passing out of the coma. After the patient passes into a stage 
of stupor he can be roused, but immediately relapses into the 
soporous state, which disappears slowly and weeks may elapse 
before he has regained his intelligence. Complete recovery of 
either intelligence or power is rare. More often there remains 
a postapoplectic dementia in which there is mental confusion 
with depression, occasionally fears and phobias, a dissatisfaction 
with the surroundings and rage at his impotent helplessness. 
With increasing mental weakness the patient becomes apathetic, 
his interest in the external world becomes less, but the dementia 
does not become complete and there is usually more intelligence 
than the dull, expressionless countenance would indicate. 

There are numerous minor symptoms depending upon the 
extent and location of the extravasation but these do not affect 
the diagnosis or treatment. 

Prognosis. — The prognosis is generally bad, especially if 
the cranial nerves are involved. A second attack is almost 
invariably fatal. The principal source of danger is in hypostatic 
congestion of the lungs and pulmonary edema. Absolute rest 
is necessary to prevent a second attack or further extravasation 
of blood and this rest favors pulmonary stasis. Rapidly forming 
bed-sores are very unfavorable signs and a rise in temperature 
during the coma is also unfavorable. A coma lasting over 
twenty -four hours is usually fatal and likewise the appearance 
of Cheyne-Stokes respiration. A favorable diagnosis can be 



CEREBRAL HEMORRHAGE 20I 

given if the coma clears up in a few hours after the attack, and 
if the fall in temperature did not exceed 2 degrees and if it does 
not rise above 103. A hemiplegia that does not improve in 
three or four months will never improve. 

Diagnosis. — The only diseases which might be mistaken 
for apoplexy are cerebral embolus and thrombus. Cerebral em- 
bolus occurs at an earlier age, there is generally a history of rheu- 
matism or endocarditis with valvular defect, or there may be 
a history of infarcts in other organs. The attack is not as 
severe, the coma not as profound, the face is pale and there are 
generally clonic spasms. In cerebral thrombus the symptoms 
come on more slowly and are not as severe, the face is pale, 
there are no spasms, the symptoms are altogether milder and 
may clear up completely. There is neither fever nor stertor in 
cerebral embolus or thrombus. In alcohol narcosis there is the 
odor of alcohol, and generally delirium and restlessness; there 
is no inequality of the pupils nor evidences of hemiplegia. The 
pulse is as in apoplexy. We must remember that apoplexy 
frequently occurs after a debauch and there may be the odor of 
liquor in addition to the signs of apoplexy. In this case we may 
find the contracted pupils of alcoholism but there is also evidence 
of paralysis, the paralyzed limb dropping more limply than the 
other, the latter responding to irritation. Diabetic and uremic 
comas give a causative history, the diabetic coma is usually 
preceded by dyspnea or vomiting and there is no paralysis, 
while in uremic coma if there is paralysis there are generally 
convulsions preceding the coma or during its progress. Exami- 
nation of the urine will clear up a questionable diagnosis. Both 
forms of coma begin in stupor and proceed to complete coma. 
Other causes of coma as epilepsy, opium poisoning, cerebral 
concussion and compression, are readily distinguished from the 
coma of apoplexy by the history and pathognomonic signs. 

Treatment. — There is no routine treatment for apoplexy as 
the same method that will avail in one case will harm another. 
Venesection, highly praised by many authorities, is extremely 
dangerous in old age. It may be of service in robust, middle- 
aged individuals where there is a full bounding pulse and flushed 
face and the certainty of correct diagnosis. In aged persons 
the withdrawal of 10 or 15 ounces of blood may produce speedy 
collapse and death. 



202 PATHOLOGICAL OLD AGE 

The most important rule in the treatment of apoplexy ap- 
plies to the first few minutes after the attack. Raise the pa- 
tient's head but do not move him. More harm is done by moving 
the patient upstairs or to a hospital within a few minutes after 
the stroke than by any subsequent treatment. He should not 
be moved for at least half an hour and in the meantime ice 
should be applied to the head and hot cloths to the feet, the ob- 
ject being to withdraw blood from the head by producing a 
local hyperemia in the lower extremities. Involuntary evacua- 
tion of the bladder and bowels generally occurs during the coma. 
If this does not occur the catheter and an enema should be used. 
During the comatose state drugs given by the mouth are liable 
to enter the larynx and bronchi and absorption by the stomach 
is slow or entirely inhibited. Whatever drugs are given during 
this time should be administered hypodermically. In case of 
threatened collapse camphor dissolved in ether should be given. 
Strychnine and digitalin can also be used but nitroglycerin is 
contraindicated. If there is a rapid full pulse aconite or vera- 
trin should be used every half hour until the pulse slows down 
and remains slow. A rapid weak pulse indicates weak heart 
and threatened collapse. The most critical period is during 
the comatose stage and all our efforts must be directed to main- 
tain the strength of the heart without increasing the cerebral 
hemorrhage. After the comatose stage has passed and the 
patient is able to swallow the further treatment is sympto- 
matic. The one main precaution is the avoidance of anything 
that might produce cerebral hyperemia or increased blood pres- 
sure. After the comatose stage the patient should be occasion- 
ally moved to prevent hypostatic congestion and an air or water 
cushion should be provided to prevent bed-sores. If there is 
jnuch restlessness morphine and bromides are indicated. For 
insomnia, veronal is best. Phosphorus is of service if there is 
dementia. For headache, frequently a distressing after-effect, 
cold applications to the head can be tried. 

If the facial paralysis subsides within a week we can expect 
a subsidence of the hemiplegia. If it persists we have a difficult 
problem to deal with. Under no circumstances should any 
attempt be made to massage or institute other treatment of the 
affected limbs within a week after the attack, and even then 
only the mildest passive motion should be attempted. There 




Chronic Interstitial Neuritis, Showing Degeneration in Some 
of the Nerve-fibers. (From Gordon's "Nervous Diseases.") The 
interstitial tissue is everywhere increased and the perineurium thick- 
ened. The patient had arteriosclerosis. 



Tremorgraph — Post-hemiplegic tremor. (Neustaedter, Med. Record, July 17, 

1909.) 



SENILE NEURITIS 203 

is always the danger that rigidity and contracture of muscles 
will develop if the paralysis persists, and we are sorely tempted 
to prevent this by motion, massage, electricity or other means, 
but if attempted too early there is the greater danger of a second 
attack. After the second or third w^eek we can begin with more 
active treatment, using vibrators, the faradic current and mas- 
sage but voluntary exercise should not be permitted for several 
weeks, and the patient should be constantly cautioned against at- 
tempting to walk or using the arms until a fair amount of power 
has returned. During the first week concentrated liquid foods, 
preferably predigested or partly digested, should be used, but 
alcohol must be avoided and this ehminates most of the prepared 
liquid foods on the market. 

SENILE NEURITIS 

Senile neuritis is a form of chronic neuritis in which the 
senile changes in the nerves appear to be an etiological factor. 
It may occur as a localized or general neuritis. 

Etiology. — In many cases an exciting cause can be found. 
This may be traumatism, sudden temperature changes, long 
exposure to cold, extension of an inflammation from adjoining 
parts, diabetes, alcoholism, lead or mercury poisoning, syphilis 
or other toxemias. Where there is a traumatic cause, the injury 
may be no more than a scratch, prick or bruise. The neuritis 
may then appear days or weeks after the injury. Decubitus 
is often preceded by neuritis. There are many cases in which 
no exciting cause can be found and aside from a concomitant 
arteriosclerosis the only assignable cause is the senile change 
in the nerve. 

Pathology. — In some cases no structural change can be 
found; in others we find the changes observed in the ordinary 
interstitial and parenchymatous types of neuritis. The senile 
form of neuritis is generally a polyneuritis of the parenchyma- 
tous type, the changes being more marked at the periphery. 
The axis cylinder is apparently not affected but there is a hyper- 
plasia of the neuroglia. The muscle supphed by the affected 
nerve undergoes fatty degeneration and the vessels become 
sclerosed. 

Symptoms. — Cases of localized senile neuritis are rare and 



204 PATHOLOGICAL OLD AGE 

the early symptoms are mild. There is never the intense pain 
associated with this type of neuritis in earlier life or when due 
to other causes, though the pain is constant and increased upon 
pressure. The reflexes are diminished but coordination is not 
affected unless the cord is involved. In some cases there is 
no marked motor or sensory impairment and the disease is 
discovered accidentally when pressing over an affected nerve 
and tenderness is found. In the multiple form of senile 
neuritis there are motor and sensory disturbances in several 
nerves, generally in those of the extremities, motion is di- 
minished but there is never complete paralysis as occurs in 
traumatic neuritis, paresthesia especially pruritus occurs but 
there is little or no pain except upon pressure. The re- 
flexes are diminished, the patellar reflex being usually lost, 
but there are no ataxic symptoms. In some cases the mo- 
tor, in other cases the sensory manifestations predominate. 
Twitching and tremors are rare and muscle atrophy is a late 
occurrence. The disease being due to the progressive senile 
degeneration of the nerve, is progressive, but the symptoms 
can often be ameliorated. 

Treatment. — If the pain is severe, a hot pack or some local 
anesthetic like cocaine, chloroform or a mixture of chloral and 
camphor will give temporary relief. The ethyl chloride spray 
should not be used, as the intense cold produced may destroy 
the surface capillaries. The treatment of the functional impair- 
ment depends upon the character of this impairment. If there 
is irritability, hot baths and internally large doses of bromide 
of sodium or potassium should be used. Diminished functional 
activity requires stimulation. Locally galvanism, vibration and 
massage can be employed. Internally strychnine and arsenic 
should be given, care being taken not to overstimulate the heart 
and to guard against the cumulative effects of the arsenic. 
When the strychnine is discontinued, caffein or theobromin 
can be substituted. 

SENILE TRIFACIAL NEURALGL/l 

Trifacial neuralgia involving the terminal fibers of the third 
branch in the bony structure of the lower maxilla is the only form 
of neuralgia bearing a distinct relation to the senile processes. 



SENILE TRIFACIAL NEURALGIA 205 

Etiology. — This form of neuralgia affects the alveolar process 
of the toothless lower jaw and is probably due to compression 
of the terminal fibers in the bony structure. It is a compression 
neuritis rather than a true neuralgia, but the symptoms are those 
of the latter. A paroxysm is produced when an attempt is made 
to crush a hard substance between the jaws, or when the jaws 
are forcibly closed ; even simple pressure upon the jaw or the 
presence of a cold substance as ice may bring it on. An attack 
may, however, come on without pressure or cold or any other 
discernible cause and whether due to pressure or any other 
cause the attack is identical in character with an ordinary 
neuralgic paroxysm. 

Neuralgia in the other branches of the trifacial nerve as 
well as in other nerves may be due to an impoverished con- 
dition of the nerve caused by arteriosclerosis. It is, how- 
ever, difficult to determine the basic etiological factor from 
the host of possible causative factors that are generally present. 
In some cases there is no structural change in the vessels or 
nerve and no other discoverable cause. 

Symptoms. — The principal symptom of this form of tri- 
facial neuralgia is a paroxysmal pain in the lower jaw, usually 
localized, occasionally occurring in several spots and if brought 
on by pressure the pain may be some distance away from the 
spot pressed upon. It may be a momentary stitch or a lancinat- 
ing pain lasting from a few seconds to many minutes with com- 
plete remission in the intervals. There are usually several pres- 
sure points along the ridge of the alveolar process, besides the 
usual one at the orifice of the inferior maxillary canal which, 
when pressed upon, intensify the pain. In the intervals between 
the attacks mild pressure upon these points does not produce 
pain, but when a certain degree of pressure is reached it is 
immediately followed by the agonizing pain which marks the 
disease. 

Treatment. — In the treatment of this form of neuralgia we 
must try to discover the basic etiological factor. If we find 
that it is a pressure neuritis and is brought on only by pressure 
upon the gums, the indication is plain; soft foods requiring no 
chewing must be given and hard particles must be avoided or 
crushed before being eaten. In many cases the neuralgic attacks 
come on when pressure upon the gums is excluded and we can 



2o6 PATHOLOGICAL OLD AGE 

find no other cause. In these cases the treatment is purely 
empirical. If quick action becomes imperative a hypodermic 
injection of morphia and atropia should be given. A 2 per 
cent, cocaine ointment made with an animal fat base will gener- 
ally give relief. A bit of cotton soaked in ether placed over the 
pressure point is also effective but the ethyl chloride spray which 
is serviceable in other localities cannot be used in the mouth. 
Whatever local treatment is used must be applied to the gums 
and this excludes many drugs which can be used upon the skin. 
The aconitin treatment which is almost a specific in functional 
neuralgias is generally inadmissible in senile cases on account 
of its depressant effect upon the heart and lungs. The combina- 
tion of aconitin and digitalin, which has been recommended by 
some authors, is irrational, as the digitalin which is added to 
overcome the depressant effect of the aconitin is slow in action, 
while aconitin acts rapidly, and may cause delirium cordis and 
paralysis of the respiratory muscles before the digitalin has 
begun to act. If the heart is in good condition the aconitin 
may be given in doses of 1/300 to 1/200 grain combined with 
twice the quantity of atropia. Electricity in various forms, 
Roentgen therapy, light therapy, hydrotherapy, massage, vibra- 
tions and other non-medicinal measures have been tried but 
none give the uniform results obtained from aconitin. The 
injection of alcohol has given relief in some cases but it is 
intensely painful and the relief is but temporary. Surgical 
treatment is rarely indicated in this form of neuralgia. When 
all other measures fail and surgical intervention becomes 
necessary the best results are obtained from the removal of 
bone around the foramen by means of the galvanocautery or 
by resection and scooping out with a bone curette — Jaire's 
operation. 

MODIFIED DISEASES OF OLD AGE 

The diseases of the third group are not senile diseases, but 
diseases which may occur in earlier life. When occurring in the 
aged they differ so greatly from those of maturity that they can 
be differentiated into two separate diseases. The senile pneu- 
monia differs in symptoms, prognosis and treatment from 
bronchopneumonia, for which it is frequently mistaken. Senile 



HAY FEVER 207 

cystitis differs from the cystitis of earlier life in etiology, path- 
ology and treatment. This group could be made to include every 
disease occurring at both periods of life for the reason that the 
senile degenerative changes modify pathological processes, com.- 
plicate symptoms, render prognosis more unfavorable and 
demand different treatment. When these differences are clearly 
marked, especially when a disease presents symptoms that are 
never found in maturity, it is placed in the third group. The 
prefix senile is added to these diseases and to all diseases in which 
it is necessary to differentiate between them and similar dis- 
eases occurring in maturity, such as senile gangrene, senile 
neuritis, etc. 

HAY FEVER 

When occurring in the aged this disease is almost always car- 
ried over from earlier life. It differs in some of its cardinal 
symptoms from the disease in maturity. Owing to the increas- 
ing atrophy of the mucous membrane, the coryza becomes 
milder year after year and may disappear entirely. There is 
usually an absence of conjunctivitis. There is, however, a 
dry irritating bronchial catarrh and asthmatic attacks with 
expiratory dyspnea, coming on at night especially if there is 
much moisture in the atmosphere. The bronchial symptoms 
increase as the nasal symptoms decrease. There is rarely fever 
or any other of the usual concomitants of the infectious diseases. 
(In this as in other diseases of this group, the symptoms that 
do not differ from the symptoms appearing in maturity, are 
generally omitted.) 

The treatment of hay fever is prophylactic and symptomatic. 
The prophylactic treatment is the same as in maturity and con- 
sists of change of climate. Those who are attacked while in the 
lowlands or near the seashore will obtain relief in the hills or 
inland where there is a dry atmosphere. The reverse holds good 
for those who are affected when in the highlands or inland. 
Every sufferer must determine for himself the locality where he 
is free from attack. Persons who had remained away for years 
from the locality in which they were formerly attacked will be 
attacked again when they return to that place. Adrenalin and 
cocaine, virtually specifics in maturity, are useless and dangerous 
in old age. The asthmatic attack can be relieved by chloroform 



2o8 PATHOLOGICAL OLD AGE 

cautiously inhaled and the internal administration of heroin in 
i/io-grain doses. 

SENILE ASTHMA 

Etiology. — The term asthma is a diagnostic placebo which 
tells the physician no more than it does the patient; i.e., that 
there is a spasmodic dyspnea. It is usually applied to bron- 
chial asthma, a disease which is rare in the aged, although 
dyspnea occurs frequently at that time of life. Spasmodic 
attacks may occur in emphysema, cardiac disease, aortic aneu- 
rysm, dyspepsia, nephritis, diabetes and various nervous condi- 
tions of the aged. 

Symptoms. — The forms included under the term senile 
asthma are pulmonary and cardiac asthma, these being directly 
due to the senile processes, emphysema and cardiac disease or 
arteriosclerosis of the coronary artery. Other forms of asthma 
and spasmodic dyspnea are readily distinguished from senile 
asthma. In bronchial asthma, which is rare in the aged, there 
is generally a history of attacks going back to maturity, there are 
the Curschmann's spirals, Charcot-Leyden's crystals, there are 
usually premonitory symptoms of sneezing, a tickling in the 
throat extending to the chest, causing a sense of irritation and 
coughing. In dyspeptic or gastric asthma the Curschmann's 
spirals and Charcot-Leyden's crystals are absent, the attack 
comes on after a heavy meal and there is inspiratory and expir- 
atory dyspnea. The dyspnea of aortic aneurysm is inspiratory 
and expiratory, being due to pressure upon the trachea or bron- 
chus, and it changes with change of position. Other symptoms 
pointing to aneurysm determine the diagnosis. Hysterical 
asthma is rare in the aged and there are other symptoms pointing 
to hysteria, while the breathing is slow or irregular. Spasmodic 
attacks of dyspnea may occur in nephritis, diabetes and various 
nervous diseases either through the effect of the disease upon the 
heart and lungs or upon the nervous regulation of these organs. 

In senile asthma the distinctive spirals and crystals in the 
sputum are absent and there are evidences of emphysema or 
cardiac disease, usually both. In the emphysematous form 
there is the reversal of rhythm and difficulty in expiration, 
while these may be absent or irregular in cardiac asthma. The 
dyspnea of emphysema comes on after exercise; in cardiac 
asthma the attack may come on while at rest and it is accompan- 



PLEURISY 209 

ied by palpitation or arrh3^thmia. This arrhythmia may, how- 
ever, occur in emphysematous asthma, as it follows exercise and 
the heart is generally affected at that period. Cardiac asthma 
occurs occasionally at night, the patient awakening out of a 
nightmare with a choking sensation, palpitation and feeling that 
he must die from suffocation. The dyspnea in senile asthma 
gradually becomes less severe and finally passes away entirely, 
generally without cough or expectoration. 

The treatment of senile asthma depends upon the cause. 
In the emphysematous asthma immediate cessation of exercise 
and lying down with the head raised will usually give relief. If 
the dyspnea persists it may be necessary to give a hypodermic 
injection of morphine 1/8 grain and atropine 1/120 grain. In 
cardiac asthma the cardiac disease upon which it depends must 
be treated. During a paroxysm the inhalation of a nitrite of 
amyl pearl will usually give immediate relief, contraindicated, 
however, if associated with chronic bronchitis. The inhalation 
of powdered stramonium, lobelia and other antispasmodics are 
useless and dangerous in either of these conditions. They are 
useful to relieve the paroxysm of bronchial asthma if there is 
no cardiac impairment. Many remedies which are useful in 
bronchial asthma in earlier life cannot be given to the aged on 
account of their depressing effect upon the heart. Chloral, 
antipirin, pilocarpine, are therefore contraindicated. Bron- 
chial asthma usually lessens in severity with advancing age and 
gives way to the senile forms. If it persists and emphysema and 
cardiac disease can be eliminated, the iodides, preferably the 
syrup of hydriodic acid and bromides in large doses should be 
used. 

PLEURISY 

The pleurisy of old age differs in some features from the 
pleurisy of early life. 

Etiology. — Senile pletirisy is almost always a secondary dis- 
ease though the primary affection is sometimes so mild as to 
give no clearly defined symptoms. In some cases the primary 
disease is latent until the pleurisy is recognized and it then ap- 
pears in an active form, being apparently secondary to the 
pleurisy. It most frequently follows pneumonia, especially 
when the inflammatory process lies close to the surface. A 
14 



2IC PATHOLOGICAL OLD-AGE 

septic infection, either local or general, may be followed by 
pleurisy, and pulmonary tuberculosis in the aged generally 
affects the pleura as well. It may also occur in typhoid fever 
and other infectious diseases. Tumors and inflammation in 
adjacent tissues may produce inflammation of the pleurae, 
though these cases are comparatively rare. In some cases no 
cause can be found and the exudate is sterile. The disease is 
much milder than in maturity. 

Pathology. — Pleurisy begins with a fibrinous exudate upon 
the inflamed site followed by an exudation of serum. The 
serum generally contains pneumococci, streptococci and staphy- 
lococci, occasionally tubercle bacilli, colon bacilli, etc. The 
septic organisms convert the clear serum into the thick, cloudy, 
purulent fluid found in empyema. In rare cases, there is a 
hemorrhagic exudate following tuberculosis or carcinoma. 
It may occur also as the result of traumatism or follow such 
rare causes as the hemorrhagic diathesis, pulmonary gangrene, 
bursting of an aneurysm, etc. The pseudochylous or chyloid 
exudate occasionally found after tapping is due to fatty degener- 
ation of pus cells. 

Much stress has been laid in recent years upon cytology and 
cytodiagnosis of pleuritic effusions. These laboratory adjuncts 
to diagnosis are rarely required except to furnish corroborative 
evidence of clinical and bacteriological findings. In the cyto- 
logical examination the number and character of the polynuclear 
leucocytes, lymphocytes, and endothelial cells are considered. 
In pneumococci c pleurisy there is a polynucleosis, marked autol- 
ysis, the endothelial cells are numerous at first and later dimin- 
ished in number. Streptococcic pleurisy has a polynucleosis, 
the cells degenerated and a large number of endothelial cells. 
Tubercular pleurisy has at first a lymphocytosis, numerous 
eosinophile cells and few red cells; later there is a polynucleosis, 
endothelial cells few and scattered. Typhoid pleurisy has a 
lymphocytosis and endotheliosis, increased eosinophiles and 
many red cells. In cardiac pleurisy there is a marked endothe- 
liosis and sometimes a polynucleosis. In malignant pleurisy 
portions of the tumor mass are sometimes found. These cy to- 
logical findings are often valueless, as there are usually pneu- 
mococci and streptococci present and the cytological changes 
produced by both are found. 



PLEURISY 211 

The anatomical changes in the pleura itself due to pleurisy 
are not well marked. The senile pleura is normally thickened 
and the surfaces may be adherent without having given any 
clinical evidences of an inflammatory process. In senile pleurisy 
the surface may be reddened and it appears swollen and rough. 
There are frequently adhesions but it cannot be stated with 
any certainty whether they are the result of the pleurisy or are 
old processes. There is never an extensive exudate and the small 
amount of this with the tendency to become fibrinous would 
favor the formation of adhesive bands and surface adhesions. 

Symptoms. — Acute idiopathic pleurisy is rare in the aged 
and the classical onset of this condition is seldom observed. 
The slight chills which usher in acute pleurisy in earlier life are 
usually absent. There may be fever due to the primary dis- 
ease, but the senile pleurisy itself causes but slight if any eleva- 
tion of temperature. In some cases w^here puncture revealed 
an empyema there was no fever. The pain is usually slight. 
There is occasionally a sharp, momentary pain or "stitch" 
over the site of the inflammation, more often there is a dull 
ache which becomes a sharp pain only when coughing, or taking 
a forced deep breath. If the diaphragmatic pleura is involved, 
the pain may radiate into the abdominal cavity and simulate 
intestinal colic or peritonitis. Dyspnea occurs frequently owing 
to the compression of the lung by the exudate. This may also 
produce cyanosis especially after exercise. The exudate may 
also press upon the heart interfering with its motion, causing 
arrhythmia or palpitation and may produce such cardiac dis- 
turbances as to cause death. The respiration is shallow, the 
patient being afraid to take a deep breath on account of the 
pain. During the early stage of pleurisy, before the serous 
exudate has developed, there is a dry painful cough without 
expectoration. This ceases as soon as the exudate keeps the 
inflamed surfaces apart. If there is a cough with expectoration 
it is due either to bronchitis or pneumonia. An empyema may, 
however, open into lung tissue and cause a purulent expectora- 
tion. The patient will bend toward the affected side and when 
lying down before the serous exudate has appeared, he will lie 
on the unaffected side so as not to compress the inflamed pleura. 
After exudation he will lie on the affected side, so as to allow 
full expansion of the clear side of the chest. 



212 PATHOLOGICAL OLD AGE 

The physical signs are not so clearly defined as in maturity. 
Owing to the rigid chest walls which move as a whole, no change 
in movement can be noted on the two sides but there is usually 
a bulging in the intercostal spaces of the unaffected side. As 
there is generally a senile emphysema with chest rigidity the 
percussion and a.uscultation sounds are altered. The percussion 
note is dull rather than fiat and the note on the healthy side is 
more tympanitic than usual. The affected side lies lower in the 
chest than the other and may displace the abdominal viscera 
below it. The auscultatory sounds are not lost entirely as in 
maturity. Friction sounds before the exudate are quite clear 
and after the serous exudate, the vesicular breathing becomes 
faint. Bronchophony is found above the level of the fluid. 
The percussion and auscultation sounds are altered when the 
level of the fluid is changed by change of position. When 
the exudation is reabsorbed or removed the normal sounds 
are heard again, although pleuritic friction sounds may be 
heard for months after complete recovery. The X-ray can 
be employed in corroborating the diagnosis. The symptoms of 
pleurisy are modified and may be partly or completely masked 
by the symptoms of the primary disease. The diagnosis is 
especially difficult if there is a co-existing pneumonia localized 
in the lower part of the lungs. In this case the early symptoms 
are often completely masked by the symptoms of the pneumonia. 
In some of these cases the first indication of pleurisy is the finding 
of friction sounds or a pain on coughing. More often there will 
be no early signs or symptoms, and not until the serous exudate 
hides the rales of pneumonia is the presence of pleurisy sus- 
pected. In many cases the only positive means of diagnosis 
of pleurisy is an exploratory puncture or aspiration. Empyema 
will generally give an irregular elevation of temperature, but 
even this may be absent in the aged, especially if there is a com- 
plicating pneumonia. Baccelli's test, a whisper heard clearly 
in serous pleurisy and lost in hemorrhagic and purulent pleurisy, 
is fairly accurate, nevertheless, the only certain test is the exu- 
date obtained by puncture. 

Treatment. — The treatment is mainly symptomatic plus 
the treatment of the primary disease. The special indications 
are the relief of pain, the removal of the fluid by withdrawal 
through aspiration or resorption, reduction of temperature and 



PLEURISY 213 

sustaining the strength of the patient. As the disease is usually 
mild in the aged, it is rarely necessary to do anything for the 
pain or temperature. If the pain is severe, local applications, 
such as belladonna plaster or belladonna ointment, cocaine 
ointment, dry or moist heat, turpentine stupes, dry cups, etc., 
will usually give relief. Narcotics and analgesics are seldom 
required. 

As the rise in temperature is usually due to the primary dis- 
ease except when empyema develops, the measures applicable 
in the primary condition are indicated. Quinine is the best 
antipyretic in septic conditions in the aged. Cold baths are 
dangerous on account of the shock and deficient reaction and 
the coal tar products are cardiac depressants. 

The removal of the exudate is the principal indication. 
The most certain measure is aspiration but there are several 
dangers connected with this procedure in the aged. The dread 
of anticipation followed by the pain of the momentary puncture 
will produce a shock causing an unfavorable reaction. The 
rapid removal of the fluid produces a partial vacuum, and to fill 
this the lungs must expand rapidly. As the emphysematous 
limg had been compressed by the fluid, its rapid distention 
causes distention of the alveoli with rupture of their walls 
and an increase in the emphysema. The puncture site is 
frequently the focus for a septic or an erysipelatous infection. 
Aspiration should be performed only if other meastues fail 
and the pressure of the effusion upon the heart or large vessels 
causes serious interference with the circulation or when the 
pressure upon the lungs causes cyanosis or distressing dyspnea. 
The puncture is made in the eighth or ninth intercostal space 
on the scapular line. A small quantity of serum should be 
withdrawn slowly and the opening rapidly closed. In some 
cases resorption is brought about through the local application 
of cataplasms, or tincure of iodine, and the internal adminis- 
tration of iodide of potassium and salicylate of soda in 5 -grain 
doses of each. This should be tried in every case after the evi- 
dences of serous effusion appear. In empyema surgical meas- 
lures are necessary. Serum therapy has been fruitless in these 
cases, resorption is impossible and it is impossible to withdraw^ 
the pus completely by puncture and aspiration. 



214 PATHOLOGIC-AJ. OLD AGE 



PULMONARY ffiTEREMIA 



Pulmonary hyperenv'a n:ay be active or passive, local or 
general. The form usually found in the aged is passive h>'per- 
emia or pulmonary congestion. Active pulmonary hyperemia 
is rare in old age. It is generally due to direct irritation of 
the lung through the inhalation of irritating vapors or gases, 
cold air. rarified or compressed air, \-iolent coughing, rapid 
heart action, excessive exercise, etc., or it may occiu* as a 
compensatory hyperemia in a healthy part of the lung when 
the circulation is impaired in another part, as happens in 
pneumonia. Infectious disease? will sometimes cause active 
hyperemia. 

Etiology. — Passive pulmonary hyperemia is generally due to 
diininished aspiratory energy of the left heart, or to mitral dis- 
ease :- ..r-ng obstruction to the return circulation. These causes 
V.-1II jr: : ..:e a general congestion. If the patient is laid up for 
any ler g:J: of time, maintaining a recumbent position, espe- 
c:?-"y rr. h:? :;. :!' :: r ':':?d gra\-itates to the most dependent 
p:r:::r- :: :hr l.rc :.- ..5::_g a hypostatic congestion. The usual 
s::e :: ::y::s::^::: ::r.zr5::?n is the lower posterior portion of 

Pathology. — Virchow first described the congestion due to 
m :ril disease. In this form the lung is hea^-y, firm, of a dark 
re d : : - : r i : rted with yellowish or brownish spots. The alveolar 
v:-:.ds .^re thickened and contain pigment granules while the 
ah-i:': 'hinselves contain loose degenerated and pigment^ 
ec tdr- .rt cells. The larger blood-vessels are enlarged and 
en 5 : r ^ r i , while the capillaries are greatly dilated and lengthened 
ar-i 5:r:.e :::?.y be ruptured, the blood extra vasa ting into the 
vradE ar. 1 rTr-or of the alveoH. A brownish fluid exudes from 
the : ut 5 rid-ir This form is called brown or pigment indiua- 
tion- In hypostatic congestion the lung is very dark and heavy, 
with little crepitation, the tissue is friable, the aveolar walls 
are swollen, the alveoli fMed with degenerated cells and the 
vessels are tirtuius id;.:ei ;.:;i Tiirrged. 

A izrrr :: oassive hyperemia occurring with some of the in- 
fett: . 5 1.5e3^;e- i? s^lerization. the pathological changes caus- 
ir.c: --- :TErr:::.i^r_:e :: i z?. tissue. The lung is dark brown 
or p'jirhsh. while the cut surface presents many reddish or 



PULMONARY HYPEREMIA 21 5 

yellowish spots where blood had extravasated into the tissues. 
The alveolar walls are swollen but the alveoli may be collapsed 
or filled with debris of degenerated epithelial cells. There is 
an interstitial edema which causes an oozing of watery fluid 
from the cut surface. This form of congestion is rare in old 
age. 

Symptoms. — The principal symptoms of pulmonary con- 
gestion are dyspnea, cough and expectoration. These symp- 
toms may occur in other pulmonary diseases and it is sometimes 
impossible to make a definite diagnosis. Pulmonary congestion 
is frequently found upon autopsy, which gave no symptoms 
during life and in many cases the first symptoms of an existing 
congestion are the symptoms of a rapidly fatal pulmonary 
edema. In acute hyperemia the symptoms come on suddenly 
or rapidly, in passive hyperemia they come on slowly, th^ hypo- 
static congestion existing sometimes for weeks before the dyspnea 
or cough becomes sufficiently distressing to receive att/ ntion. 
In brown induration the disease progresses still more =1owly. 
The cough is loose and produces little distress. The dy >r:'nea is 
severe in splenization and hypostatic congestion, but ^'^ hrown 
induration the process of the disease is so slow that th tient 
gradually accustoms himself to the progressive dimin ;t^n of 
sufficiently oxygenated blood. Physical exercise naturally in- 
creases the dyspnea. There is no pain and in some ca- there 
is no distress other than a feeling of tightness, or oppre-<'on in 
the chest. When the disease is far advanced and aerate ^n be- 
comes much impaired cyanosis appears and prostratior ^ -^curs, 
followed by pulmonary edema and death. The expec t^-ation 
in brown induration contains degenerated, pigmented r;l, eolar 
cells but rarely blood. In the hypostatic form there f r blood 
streaks and spots. The expectoration is profuse and watery, 
differing from the blood-streaked sputum of pneumonia vvhich is 
scanty and tenaceous. The respiration is hurried and in hypo- 
static congestion it is confined to the upper part of the lung^. 

The physical signs are dulness upon percussion oa, er the 
affected area, moist rales and absence of the vesicular murmur. 
In hypostatic congestion prolonged change of position will 
shift the location of the congestion or cause it to disapper-r alto- 
gether, but it will return upon prolonged rest in the o^-ginal 
position. The congestion in the brown induration is permr nent. 



2l6 PATHOLOGICAL OLD AGE 

The vesicular murmur in hypostatic congestion is feeble or lost 
over the affected area ; in brown induration the inspiratory sound 
is rough, while expiration is prolonged. Rales appear with the 
edema and are really symptoms of pulmonary edema (see 
Pulmonary Edema). Although the symptomxS and signs of 
pulmonary hyperemia may occur in other pulmonary diseases 
the diagnosis is not difficult . Absence of fever and slow pro- 
gressive onset distinguish passive hyperemia from acute inflam- 
matory conditions. The sputum alone will suffice to differen- 
tiate it from pneumonia. The early stage of chronic interstitial 
pneumonia gives similar symptoms but the history wil] serve to 
distinguish between the two diseases. 

Treatment. — The treatment depends upon the cause. In 
hypostatic congestion frequent change of position is necessary. 
In all forms the underlying cardiac disease must be treated. 
Occasionally the Bier hyperemia treatment or other measure for 
producing local hyperemia in some other part of the body will 
break up a passive pulmonary hyperemia, expectorants like 
senega, ipecac, squills, are useful, but the narcotics are contra- 
indicated. Compensatory hyperemia requires no treatment. 

SENILE PNEUMONIA 

Faulty nomenclature, multiplicity of terms, diverse views 
as to the etiology and pathogenesis of pulmonary inflammation, 
and as to the interpretation of its signs and symptoms are 
responsible for the confusion that exists relative to the various 
pathological conditions included under the term pneumonia. 
Some authorities will include under this term only those condi- 
tions that are due to bacterial activity, others include non- 
bacterial inflammations of the lung. A simple hyperplasia 
without inflammation is called interstitial pneumonia and 
many writers call capillary bronchitis, bronchopneumonia 
though the lung tissue may not be involved. All forms 
of pulmonary inflammation, infectious and non-infectious, 
may occur in old age and when occurring are modifled by 
the senile changes. (As the infectious forms are really 
constitutional diseases with localized manifestations they 
will be treated under the infectious diseases of the fifth group.) 
The term senile pneumonia is here applied to a non-infectious 



SENILE PNEUMONIA 21 7 

inflammatory process in the lung of the aged. It may be local- 
ized or diffuse, primary or secondary, acute or chronic, mild or 
virulent, or latent, masked or abortive. In many cases a non- 
infectious pneumonia becomes an infectious one, the diseased 
tissue being a fruitful field for germ growth and development. 

The primary senile pneumonia is generally acute and in most 
cases rapidly fatal. The secondary form is usually latent or 
masked and its existence is frequently not suspected until the 
terminal edema sets in, or if death is due to another cause, its 
presence is first discovered upon autopsy. The acute form is 
generally virulent, the secondary form is usually mild. Both 
forms may be localized or diffuse, the extent depending mainly 
upon the cause. Several localized areas may, by extension and 
consolidation, become a single large area of inflammation. 

Etiology. — Primary senile pneumonia is generally due to 
sudden temperature changes when the surface becomes chilled 
or cold air is inhaled. Loomis says nine-tenths of all cases occur 
between November and May. Owing to the weakened heat 
regulation in the aged, reaction to the sudden chilling of the 
surface is neither rapid not complete and the blood dammed 
back from the surface engorges the adjoining viscera. In many 
senile cases there is a pulmonary congestion due to valvular 
disease and the sudden influx of blood converts the passive 
hyperemia into an active inflammation. When cold air is 
inhaled an active hyperemia must be produced in order to raise 
the cold air to the temperature of the body. The usual effect of 
the breathing of cold air is a bronchitis produced by the frequent 
alternation of temperature of the inspired cold air and the expired 
warm air. The capillaries of the vesicles become alternately 
engorged and contracted and thus an inflammatory process is 
instituted. Noxious and irritating vapors cause inflammation 
by irritating the lining of the bronchi and vesicles. 

Secondary senile pneumonia generally follows a hypostatic 
congestion or brown induration, the passive hyperemia being 
converted into a low inflammatory process, through blood 
changes occasioned by another disease. It may also occur 
through the extension of a bronchitis or pleurisy, rarely a 
pericarditis. 

Pathology. — The usual pathological changes are such as 
occur in pulmonary h^^peremiia, followed by red hepatization 



2l8 PATHOLOGICAL OLD AGE 

of a primary pneumonia. The lung usually presents several 
small or one or two large areas of surface hyperemia and upon 
section there may be a uniform dark brown, smooth, moist 
surface, or if the disease is diffused there will be dark brown 
spots or patches. Under the microscope the alveoli appear 
larger, due to the emphysema which is almost invariably present, 
and the vesicles are filled with the debris of degenerated epithe- 
lial cells, mucus, blood cells or blood pigment and sometimes 
fibrin. The capillaries are enlarged and engorged and some may 
be ruptured. There is sometimes an interstitial edema and it is 
often difficult to determine whether there is an inflammatory 
process or a purely mechanical hyperemia with edema. In 
senile cases presenting no pulmonary symptoms until the ter- 
minal edema, it is generally impossible to differentiate between 
senile pneumonia and hyperemia with edema. The presence of 
fibrin in the alveoli, found at autopsy, always indicates an inflam- 
matory process. 

Symptoms. — Senile pneumonia generally begins with symp- 
toms so mild that they are not noticed until the disease is far 
advanced. A distinct chill and fever indicate infection. In 
primary senile pneumonia there may be a sensation of chilliness 
after exposure, the patient feeling that he cannot get warm, 
that he feels cold all through. This is followed by malaise, 
languor, and uneasiness, the patient says he does not feel well 
yet cannot assign the discomfort to any locality. He may say 
he has not slept well and is disinclined to leave the bed. After 
a day or two of such vague sensations there may be a slight 
fever, headache, dyspnea, the breathing becomes shallow and 
rapid, a cough with little mucous expectoration follows, or an 
existing bronchitis is aggravated. There is no pain but an 
oppressive feeling in the chest, the patient frequently striking 
his chest as though to dislodge some mucus. He becomes 
rapidly weaker and dies from exhaustion. In other cases 
cerebral symptoms appear after the second or third day and the 
patient has a low muttering delirium which the family mistakes 
for talking in his sleep. In some cases pulmonary edema sets in ; 
this occurs generally in secondary senile pneumonia following 
another disease (not secondary through extension of an adjoin- 
ing inflammation but through blood changes). In another set 
of cases the disease begins with rapid prostration followed by 



SENILE PNEUMONIA 219 

the pulmonary symptons of rapid, shallow breathing, dyspnea, 
a distressing cough and a tenacious mucous expectoration. A 
pneumonia follov/ing a bronchitis, pleurisy or pericarditis 
begins with a marked rise in temperature, while if secondary to 
a disease producing blood changes the symptoms may be latent 
or masked by the more pronounced symptoms of the primary 
disease. The symptoms common to all forms of senile pneu- 
monia are prostration, rapid shallow breathing and cough. 
The dyspnea may not be pronounced, as in his exhausted con- 
dition the patient will not make the powerful efforts to get air 
and there will be cyanosis instead. Striking the chest appar- 
ently to dislodge mucus occurs generally when the air vesicles 
become filled with mucus or other material. The expectoration 
may be blood-streaked when a powerful effort is made to bring 
up the mucus and a capillary is ruptured by the strain of cough- 
ing. While primary senile pneumonia, occurring when the 
patient was healthy, gives early symptoms of pulmonary disorder, 
secondary senile pneumonia may give no clear symptoms at 
any time. An increase in temperature during an acute disease 
points to some complication ; an increase in the rate of respira- 
tion during the course of an acute or chronic disease points to 
pneumonia. The respiration is usually so shallow that, unless 
there is an accompanying dyspnea, attention is not attracted 
to it. The neglect to count the respirations is responsible for many 
errors in the diagnosis where pneumonia is present. In hypo- 
static pneumonia following hypostatic congestion, the lower por- 
tion of the lung is affected and the physical signs are found over 
the posterior lower portion of the lung. Where scattered areas 
are involved, the physical signs can often be found at the apex, 
in the interscapular space and in the infraclavicular spaces and 
occasionally at the sides. There is percussion dulness over 
the affected areas, adjoining tympanitic areas, and fine crepitant 
rales are heard at the end of inspiration and beginning of expira- 
tion. The expiration is prolonged. The respiratory sounds 
are diminished and vocal fremitus may be increased. The 
percussion note may be altered if there is a portion of emphy- 
sematous lung over the inflamed area, the fine rales may be 
masked by the coarser rales of bronchitis or by the friction 
sounds of pleurisy or pericarditis. 

In differentiating between senile pneumonia and other con- 



220 PATHOLOGICAL OLD AGE 

ditions we have no pathognomonic sign, no symptom complex 
to guide us and it is often necessary to make our diagnosis by 
exclusion. Acute inflammations can generally be excluded by 
the absence of fever, or initial chill. The infectious pneu- 
monias can be excluded by the absence of high temperature and 
pathogenic germs in the sputum. Tuberculosis is slow, there is 
not the rapid prostration, it responds to the tuberculin test and 
the bacilli are found in the sputum. Influenza has marked 
initial symptoms, fever, mucous inflammation, conjunctivitis 
and presents pathogenic germs. Pleurisy with effusion gives 
percussion flatness with change of level when the position is 
changed, the intercostal spaces bulge, no respiratory sounds are 
heard through the effusion, the cough is distressing and there 
is not the feeling of irritating mucus which induces the pneu- 
monic patient to strike his chest in an effort to dislodge it. The 
secondary pneumonia following pleurisy, is either a hypostatic 
pneumonia giving no symptoms until edema sets in, or an 
infection with rapid rise of temperature. Capillary bronchitis 
or bronchiolitis gives no percussion dulness, expiration is not 
prolonged, there is not the profound or rapid prostration and 
the rales may disappear for a time after expectoration. If 
pneumonia follows a bronchitis the temperature is suddenly 
raised, the cough is more severe, expectoration is scantier, the 
respiration is hurried and shallow, there may be dyspnea and 
cyanosis and rapid prostration. In all cases of secondary 
senile pneumonia a rapid increase in the gravity of the primary 
disease with increased temperature, prostration and shallow, 
rapid breathing indicates a pneumonic complication. 

Latent pneumonia may exist as a primary disease without 
giving any symptoms and the patient expires suddenly while 
apparently in perfect health, or there may be vague symptoms of 
malaise and weakness lasting several days when pulmonary 
edema suddenly develops and is rapidly fatal. This form of 
pneumonia occurs frequently in senile dements whose weakened 
mental powers are unable to comprehend the urgent symptoms. 

Inhalation, aspiration and deglutition pneumonias , generally 
classed as bronchopneumonia, are due to the inhalation of 
noxious or irritating vapors or to the lodgement of a foreign 
body in the trachea or bronchi. The symptoms of deglutition 
pneumonia are localized to the part in which the foreign body 



SENILE PNEUMONIA 221 

is lodged and later to the part of the lung supplied by the 
branches of the bronchus which is blocked. The inhalation pneu- 
monia is a diffuse pneumonia from the onset. These forms of 
pneumonia are rare in the aged and when occurring give pro- 
nounced symptoms of primary senile pneumonia with intense 
dyspnea and rapid prostration. They begin as a non-infectious 
inflammation but infection soon sets in. 

Treatment. — The principal indication in the treatment of senile 
pneumonia is the prevention of the fatal complications of gen- 
eral exhaustion, cardiac exhaustion, hypostatic congestion and 
edema and cerebral complications. The most frequent cause 
of death is cardiac exhaustion and this is often traceable to 
the injudicious use of cardiac stimulants. When the heart 
is working near the hmit of its functional capacity further 
stimulation will suddenly paralyze or rapidly exhaust that 
organ. Cardiac stimulants should never be given in pneu- 
monia before the heart becomes w^eak. Cardiac therapy in 
pneumonia follows the general rule for cardiac therapy in 
other conditions. A full rapid pulse requires cardiac depres- 
sants like aconite, veratrum and gelsemium cautiously admin- 
istered. The coal tar depressants should never be given. A 
weak rapid pulse requires heart tonics like digitalis, stro- 
phanthus, coffee or cactus. A weak slow pulse requires spar- 
tein or strychnine. A full slow pulse requires the nitrites. 
Emergency drugs in threatened heart failure are strychnine, 
ether, camphor, the combination of strychnine, nitroglycerin 
and digitalin used hypodermically and alcohol or ammonia 
carbonate internally. In senile pneumonia the heart is weak 
from the start and mild cardiac stimulants like caffein or cactin 
can be given. As soon as heart failure is threatened, the more 
powerful stimulants are required. Digitalis should not be 
given, as on account of its powerful vasoconstrictor effect, 
the blood supply to the lungs is still further diminished. The 
rapid prostration is best combated by concentrated food, 
alcohol, strychnine, arsenic and phosphorus. The strychnine 
and arsenic can be combined as arsenate of strychnine given 
in doses of i/ioo grain. Phosphorus should not be used until 
there is marked exhaustion when it can be given in doses of i/ioo 
grain of the ordinary yellow phosphorus or 2 grains of the amor- 
phous red phosphorus. 



22 2 PATHOLOGICAL OLD AGE 

Frequent percussion is necessary to determine the presence of 
hypostatic congestion. The treatment is repeated change of 
position. 

Cerebral symptoms may be due to high temperature, 
toxemia, disturbed cerebral circulation or deficient oxygenation 
of blood, the last being the usual cause in senile pneumonia. 
High fever does not occur in senile pneumonia, and the only 
toxemias aside from pathogenic bacterial toxins that may occur 
are autointoxications from the absorption of the products of 
intestinal decomposition or from retention of urea. Carbonic 
oxide intoxication, due to incomplete aeration, is evidenced by 
cyanosis. Respiratory stimulants are required, the most power- 
ful being atropine. It can be given in doses of 1/120 grain. If 
there is a sallow cyanosis beginning with a pale face, nitro- 
glycerin hypodermically or nitrite of soda by mouth should be 
added to the atropine. If there is a purplish cyanosis beginning 
with a flushed face, the atropine should be given alone. Oxygen 
is of temporary utility in relieving the cyanosis and cerebral 
symptoms but it does not influence the inflammatory process. 
Urea intoxication is infrequent in senile pneumonia. The treat- 
ment of it consists in renal stimulation by vegetable diuretics. 
If rapid action is required, as in threatened uremia — a rare 
contingency in senile pneumonia — the nitrate of soda or potash 
should be used in 5 -grain doses every three hgurs. For intes- 
tinal autointoxication the proper remedies are active cathartics 
and intestinal antiseptics, pieferably salol and the sulphocar- 
bolates. There is no speciflc treatment for senile pneumonia. 
In some cases a hyperemia produced in some other portion of 
the body will relieve the pulmonary congestion. This can be 
done by hot foot baths, hot cataplasms applied to the chest or 
back or dry cups. These measures may avail in the beginning 
of the disease but not later. In ordinary cases none of the symp- 
toms, except perhaps the cough and difficult expectoration, 
are distressing enough to attract the attention of the patient. 
There is rarely any pain but there may be a feeling of tightness 
or oppression in the chest. This may sometimes be reheved 
by hot poultices. Narcotics, especially the opiates, should not 
be given in this disease. If there is a distressing cough with 
little expectoration we can use equal parts of the syrup of the 
hypophosphite of ammonium, syrup of senega and syrup of 



SENILE ACUTE GASTRITIS 223 

ipecac in teaspoonful doses. The inhalation of a solution of 
menthol in eucalyptol will stimulate the secretion from the 
mucous membrane of the bronchial tubes. For the dyspnea 
we can use a combination of atropine and strychnine, using 
1/120 grain of atropine and 1/120 grain of strychnine. It can 
be given by mouth or hypodermically. Dyspnea is, however, 
rarely severe enough to require treatment. For insomnia we 
can use veronal, proponal or urethane. The carbamide group 
of hypnotics is safer than the methane group where there is im- 
paired aeration of blood. 

Hygienic regulations are of the greatest importance in senile 
pneumonia. Fresh dry air, sunshine, a temperature between 
70° and 75°, no draughts, are imperative. A cheerful companion 
has a beneficial effect. There should be a daily evacuation of 
the bowels and the quantity of urine and urea passed daily 
should be noted. During the height of the disease we can use 
the liquid predigested foods in addition to simple carbohydrates 
but no meat. If convalescence occurs the patient should be 
instructed to take deep breaths even if they do cause spells of 
coughing. Warm clothing must be worn for months after 
recovery. 

SENILE ACUTE GASTRITIS 

This is the disease known to the layman as acute indigestion 
and is a frequent cause of death in the aged. It is due to an irri- 
tation of the degenerated stomach, generally caused by some 
dietetic error. 

Etiology. — We must remember that the senile stomach has 
atrophied walls, there is a waste of the glandular element, and 
usually dilatation, which is more pronounced in beer drinkers 
and in those who habitually take too much food. There is a 
chronic gastric catarrh with slow digestion and abnormal fer- 
mentation. In this condition, causes too slight to be of any 
deleterious effect in the normal stomach of maturity will have 
grave results in the aged. The most frequent cause is over- 
eating, especially while the stomach is still partly filled with 
food which is in the process of active fermentation. This 
accounts for the many cases of acute gastritis during banquets 
when food is taken shortly after the regular meal. In some 



2 24 PATHOLOGICAL OLD AGE 

cases the cause can be traced to the ingestion of partly decom- 
posed food, especially cold storage, canned and chemically pre- 
served food. 

Pathology. — The mucous membrane of the stomach is red- 
dened but there is never the intense congestion found in the same 
disease of maturity. Swelling of the membrane is rare but 
erosions are frequently observed. The secretion of mucus is 
diminished owing to the waste of the mucous glands. The 
presence of a large quantity of mucus in the vomitus indicates 
that some intense irritant to the glands has stimulated them 
to abnormal activity. The stomach is distended with food -and 
gas, pressing upward when the patient is erect, and bulging 
outward when he is lying down. 

Symptoms. — The earliest symptoms are usually a feeling of 
distress and heaviness in the stomach with eructation of gas. 
Sometimes the pressure upon the diaphragm produces singultus, 
more often it causes gastric asthma through interference with 
cardiac action, and we have then symptoms of cardiac irritation, 
palpitation of the heart, weak, irregular pulse, dyspnea, vertigo, 
faintness and pallor. If the face is flushed there is danger of 
apoplexy. Vomiting may occur, although it is rare in old age. 
The eructation of gas gives temporary relief and if vomiting 
occurs the relief is more permanent. 

Treatment. — The greatest danger from this form of gastritis 
is cardiac irritation; secondary dangers arise from prostration 
and from the direct injury to the gastric walls. The first danger 
is temporarily removed by putting the patient upon his back, 
thereby relieving the pressure upon the heart from below 
After a few minutes the patient can be placed in a semirecumbent 
position and pressure can be made over the stomach to dislodge 
the gas. It is a mistake to prevent eructations. The patient 
attempts to suppress this, owing to his mistaken sense of pro- 
priety, but the physician who attempts to prevent it is guilty of 
the grossest ignorance. The rational treatment in these cases is 
to empty the stomach as soon as possible. Where the stomach is 
overfilled, emetics will have little effect unless given in such large 
doses as to injure the walls of the stomach. The senile stomach 
is less sensitive to gastric irritants and the emetic mixing with 
the mass of food either loses its action or the action is slowed 
and prolonged. The most rapid and reliable emesis in these 



SIMPLE CHRONIC GASTRITIS 225 

cases is produced by a hypodermic of i/io grain of apomorphine. 
This should be combined with 1/2 grain of caffeine if the heart 
is weak. If vomiting occurs while the patient is unconscious 
he should be placed upon his side or almost upon his face with 
the head lowered to prevent aspiration of vomited matter. The 
strain of vomiting may be severe enough to produce prostration. 
In this case we can give strong black coffee or champagne 
or some other alcoholic stimulant greatly diluted. In an emer- 
gency where there is danger of death from exhaustion we must 
resort to the more powerful drugs like strychnine, di gitalin, 
camphor, etc., given hypodermically. A localized pain after 
an acute attack indicates an erosion which may develop into 
an ulcer or may be the focus for a carcinoma. If such pain 
exists the subnitrate of bismuth in 5 -grain doses is indicated and 
if the pain is severe or there is persistent nausea we can add 
cocaine in i/8-grain doses. If the gastric attack is mild, vomit- 
ing should be induced by irritating the fauces or by giving 1 5 or 
20 minims of the fluid extract of ipecac, mustard, or salt 
water or any other handy emetic. The same measure should 
be taken if an acute attack is due to decomposing food. After 
some relief has been obtained a vegetable cathartic should be 
given combined with the bile salts. Occasional massage over 
the fundus may be necessary to secure dislodgment of food that 
may be lying in the pouch as the flaccid walls of the stomach 
might permit a sinking of the fimdus below the pyloric orifice. 
No food should be taken for several hours after the stomach has 
been emptied. 

Simple Chronic Gastritis 

Etiology. — Simple chronic gastritis is generally due either 
to repeated attacks of acute gastritis or to the constant irritation 
of the stomach by improper food or drink. It may also occtu- in 
gastric ulcer or cancer, in diseases which cause local passive 
hyperemia, in diseases of the liver with impaired portal circula- 
tion, in heart disease, and in some constitutional diseases as dia- 
betes, gout, anemia, tuberculosis, etc. 

Pathology. — The walls are usually thickened, the mucous 
membrane is pale and covered with a thick layer of mucus. 
If there is passive hyperemia the veins become dilated and 

IS 



226 PATHOLOGICAL OLD AGE 

are prominent. The glands are sacciilated and may form cysts 
if their openings are blocked. Late in the disease, the walls 
grow thin, but shrinking of the organ which occurs frequently 
in maturity does not occur in the aged. 

Symptoms. — The symptoms of chronic gastritis are the 
same as those of acute gastritis, but milder and more persistent. 
There is a constant sense of discomfort about the stomach more 
pronounced when food is taken. Morning nausea and retching 
occur and bile-stained mucus may be vomited. In some cases 
food is vomited after every meal and (if this occurs) several hours 
later the vomited material has a sour odor from acid fermen- 
tation. Constipation, intestinal colic, palpitation of the heart 
and psychic depression are usual secondary symptoms. 

Treatment. — The treatment which is dietetic, hygienic and 
medicinal should follow the lines laid down for senile gastric 
catarrh; alcoholics should, however, be forbidden. If it is 
secondary to another disease the cure may depend upon the 
treatment of the primary disease. 

SENILE DIARRHEA 

Etiology. — Diarrhea occurring in the aged is generally due 
to the faulty character, too great frequency or excessive amount 
of food taken. Owing to the senile changes in the stomach 
and intestines with diminished metabolic activity, a smaller 
amount of food is assimilated. If the appetite is not diminished 
and as much food is taken as during maturity, the demands on 
the stomach and intestines become excessive and frequent stools 
result. In some cases food passes unchanged into the intestines 
and may pass out unchanged causing senile lientery. Diarrhea 
may occur as a symptom of inflammatory or ulcerative condi- 
tions of the bowel but these can be readily distinguished from 
the simple chronic diarrhea of the aged. (See Enteritis.) 

Symptoms. — Senile diarrhea comes on slowly, the patient 
becoming gradually accustomed to two or three stools a day. 
If the amount of food is not diminished the number of stools 
or the quantity of the feces will be increased. The stools may 
be normal in color and consistency or they may be lighter and 
thinner than normal but they are never fluid. There is no pain 
or tenesmus and aside from the frequency of the stools there 



SENILE DIARRHEA 227 

is no discomfort. They contain little or no mucus and no 
blood. 

Catarrhal diarrhea is infrequent in the aged as the mucous 
membrane is atrophied, and its secretion diminished and it 
requires a violent irritation to produce an enteritis with mucous 
discharges. In this form of diarrhea there is some mucus 
in or surrounding the stool mass and when due to an acute 
inflammation or ulceration there is usually blood, and occasion- 
ally pus. 

Serous diarrhea, due to intestinal irritation from undigested 
food is a watery, brown, offensive discharge which irritates the 
anus, and if it passes through impacted feces, it breaks off 
portions which come away in scales. 

Nervous diarrhea is duetto strong emotion and stools first 
normal are followed by a watery discharge. 

The diarrhea of chronic intestinal catarrh is a mucous diarrhea 
generally with pain and borborygmi. The stools are not fre- 
quent, often not exceeding one daily, and they are sometimes 
of normal appearance, sometimes watery. (See Enteritis.) 

The diarrhea of simple ulcerative colitis contains particles of 
undigested food and occasionally blood, the diarrhea alternates 
with constipation and there is pain or an uncomfortable feel- 
ing in the lower part of the bowel, besides loss of strength, emacia- 
tion, cachexia, etc. It occurs most frequently in men past mid- 
dle age. 

In all ulcerative and inflammatory diarrheas the lessened 
intake of food will diminish the amount, but will not alter the 
character of the stool. Intestinal parasites may cause diar- 
rhea but these generally give symptoms pointing to their pres- 
ence. In all cases of diarrhea an examination of the stools is 
necessary to determine the presence or absence of blood, mucus, 
pus, undigested food, shreds of tissue, and parasites. 

Treatment. — The first indication in the treatment of senile 
diarrhea is to regulate the food, diminishing the quantity and 
frequency. Food should not be given oftener than in five-hour 
intervals. If there is lientery, the character of the undigested 
food should be determined and if possible the digestant of that 
form should be supplied or that variety of food withdrawn. 
Light colored and offensive smelling stools require the bile salts. 
In some cases a senile diarrhea can be cured by giving a 



2 28 PATHOLOGICAL OLD AGE 

saline cathartic followed by a day's starvation. This should 
be the routine treatment of every case and the further treat- 
ment regulated by the result. If the diarrhea persists bismuth 
subcarbonate should be given in 5 -grain doses every two hours 
for a day, then every four hours until the stools are normal in 
quantity and frequency. It is rarely necessary to resort to the 
mineral astringents, lead sulphate or copper sulphate. Should 
it be necessary, either one can be given in 5 -grain doses three 
times a day. A starch enema will check a profuse diarrhea. 
In every case the regulation of food is of primary importance. 

SENILE CYSTITIS 

Etiology. — This is a form of chronic cystitis due to disten- 
tion of the bladder and the presence of decomposing urine 
retained either in the cystic pockets formed in the process of 
senile degeneration of the organ or in the bladder through pros- 
tatic obstruction. When bacteria are introduced from without, 
as by a dirty catheter, the disease begins as a mild acute cystitis. 
In many cases of chronic cystitis there is a history of gout but 
the connection between the two is uncertain. The old theory 
that the enforced rest imposed by an attack of acute gout causes 
retention of urine with atony and dilatation of the bladder, the 
retained urine producing a chronic cystic catarrh, is hardly 
tenable as an explanation of the relation between the two dis- 
eases. It may explain the frequency of chronic cystitis when- 
ever prolonged rest in bed is enforced. It is more probable 
that the increased amount of uric acid in the urine is responsible 
for the irritation of the mucous lining of the bladder. This, 
however, does not cause the senile form of chronic cystitis in 
which there is an absence of glairy mucus found in the ordinary 
form. The ordinary form of chronic cystitis may occur in the 
aged either as a sequel to an acute cystitis, or to the irritation 
produced by a stone or growth, or by the urine the character of 
which had been altered through retention, increased acidity or 
by abnormal constituents. 

Symptoms. — In senile cystitis there are the usual symptoms 
of senile degeneration the presence of pockets being revealed by the 
immediate finding of some more urine in a bladder which had 
been thoroughly emptied by catheterization; especially is this 



MODIFIED DISEASES OF THE SKIN 229 

the case if the patient changes his position rapidly from side to 
side and is recatheterized. In addition to these symptoms there 
is a constant dull ache, increasing upon pressure or whenever 
the bladder is distended. This ache comes on gradually, is 
never severe but persists after the bladder is emptied. The 
urine is generally turbid, ammoniacal and contains bacteria. In 
the ordinary chronic form there are the same symptoms of 
persistent ache and ammoniacal, rarely acid, urine, but the 
urine contains a glairy mucus, and sometimes pus, and there is 
frequently ulceration of the mucous membrane with more pro- 
nounced pain and painful pressure points. There is also in 
both forms a frequent desire to urinate though the bladder 
contains but a few drops of urine. The ordinary form gives a 
history of stone, growth, or an acute cystitis. In rare cases 
there is a history of urethritis, more often one of gout or chronic 
rheumatism. 

Treatment. — In the senile form of cystitis the treatment is 
primarily that of degeneration or hypertrophy. The bladder 
should be frequently emptied, care being taken to thoroughly 
sterilize the catheter. Catheterization can be entrusted to the 
patient with strict injunction as to cleanliness. A urinary 
antiseptic, preferably hexamethylenamine, should be given in 
5 -grain doses three times daily until the disappearance of 
turbidity shows that the urine is free from bacteria. Oil of 
sandalwood in lo-minim doses three times a day will relieve 
the irritability of the bladder. Irrigation is of little service 
in this form of cystitis except as a momentary cleansing wash. 
A 2 per cent, solution of boric acid or a 4 per cent, solution of 
sodium borate can be used, but the stronger silver solutions 
are contraindicated. 

MODIFIED DISEASES OF THE SKIN 

While almost all affections of the skin present peculiarities 
in the aged due to the senile changes of the skin a few present 
such pronounced modifications that they will be described sepa- 
rately. In this group will also be placed diseases which occur 
most frequently or exclusively in the aged and which would 
therefore belong to the fourth group (preferential diseases). 
Some of these diseases as well as the benign and malignant 



230 PATHOLOGICAL OLD AGE 

growths are apparently perversions of the normal senile changes 
in the skin. The true senile diseases of the skin are senile 
pruritus, the vascular group, senile purpura, and senile gangrene, 
the benign growth group, senile angioma, sebaceous nevi, warts, 
keratoma and cornua, the malignant growth group and the 
senile changes in the hair, nails and glands. 

As it is impossible to harmonize the divergent views of der- 
matologists as to the etiology or pathology of diseases giving 
similar chnical symptoms, and as the chaotic state of the nomen- 
clature still further tends to confusion, it was deemed best to 
adhere to the nomenclature adopted by Jadassohn whose work 
in senile dermatoses is best known. His views are generally 
followed where they do not conflict with the views of the author. 

(A frequent source of error in dealing with senile affections 
of the skin is senile pruritus, unassociated with the lesion, but 
which, occurring in the same region, would make it appear as a 
pruritic affection. The history of a possible antecedent pruritus 
should be sought for in every case before deciding upon a diag- 
nosis.) 

SENILE PURPURA 

Senile purpura appears in two forms. Transitory senile 
purpura occurs as hemorrhagic macules or papules on the lower 
limbs of aged individuals in whom there are local circulatory 
disturbances such as varicose veins or generally weak circula- 
tion. The spots appear after prolonged standing or walking 
and disappear when the limbs are at rest in a horizontal posi- 
tion. It is probably due to capillary engorgement brought 
about by gravitation and weakened return circulation. The 
affection is insignificant, producing no distress, and is not 
amenable to treatment. Yellowish discolorations may remain 
for some length of time. 

Permanent senile purpura occurs most frequently on the 
back of the forearms and hands, especially in those accustomed 
to work with the forearms exposed. It begins in brick red 
spots which increase in size and become confluent. Later they 
are surrounded by a reddish border while the macules become 
darker and assume the color of blood. After a few weeks the 
color becomes brown and turns gradually lighter until after 



SENILE ANGIOMA 23 1 

a few months the spots have disappeared entirely or leave 
but a slight discoloration. The eruption occurs in groups and 
may reoccur at irregular intervals. The disease is probably due 
to ruptured degenerate capillaries with transudation of blood 
into the surrounding tissue. It produces no distress, does not 
affect the health and nothing can be done for it. Slight trauma 
may produce serious hemorrhage in these cases. Purpura 
facticia senilis, described by Jadassohn, is a purpura produced 
on the back of the forearm when a rough object is rubbed over 
it. It resembles the permanent form. 

SENILE ANGIOMA 

Senile angioma or capillary varix is a frequent affection of 
the aged. 

Etiology. — Its etiology is unknown but it occurs most fre- 
quently among those much exposed to variations of tempera- 
ture without sufficient protection. It is more often met with 
in the country than in the city. 

Pathology. — The angioma consists of a minute mass of dilated 
capillaries lying under the epidermis and sometimes imbedded 
in the deeper layers of the derma. It thus forms a cavernous 
body filled with blood. In rare cases the blood is coagulated 
forming thrombi. 

Symptoms. — The angioma appear as dark red, round or oval 
macules rarely larger than a pin's head. If much larger they 
may be felt as smooth elastic papules. If deeply situated the 
color may be purplish or blue and under glass pressure the color 
becomes fighter but does not disappear entirely. The favorite 
location is on the back and chest but they may appear in other 
localities and there is no regularity in their distribution. A 
senile angioma on the free border of the lips is described by 
Pasini. It occurs generally as a solitary lesion on the lower 
lip near the median line, the color is dark red, and there are 
sometimes fine branch-like projections. The angioma produce 
no distress, and the patient is often unconscious of them. They 
may persist for years and do not affect the health. 

Treatment. — Nothing need be done for angioma. Should 
their removal be desired for cosmetic reasons electrolysis, 
thermocautery, galvanocautery or other cauterization will 



232 PATHOLOGICAL OLD AGE 

effect a cure. There is, however, danger of producing more 
serious skin lesions. 

SENILE SEBACEOUS NEVI 

These are white or yellowish, rather hard papules, the size 
of the head of a pin or slightly larger generally found on the fore- 
head and occasionally on the cheeks and nose. They are some- 
times covered by fine telangiectases. They usually contain 
two or three enlarged pores, often topped by comedones, from 
which sebum can be expressed. It is a question whether they 
are nevi or simply hypertrophied sebaceous glands. They are 
insignificant lesions, producing no distress nor interfering with 
health. They are important, however, from a diagnostic point 
as they may be mistaken for soft nevi, molluscum contagiosum, 
milium, warts or beginning epithelioma. The diagnosis is based 
upon the expression of sebum and the ability to compress the 
papule afterward. 

No treatment is required except on cosmetic grounds. A 
simple method is to squeeze out the sebum, wash the spots with 
alcohol, then apply a solution of tannic acid. If this fails, ex- 
cision or electrolysis must be resorted to. 

SENILE KERATOMA 

Senile keratoma, called also precancerous senile keratosis, 
senile dandruff, concrete sebaceous acne, etc., is a warty growth 
occurring generally upon the face and dorsum of the hands, 
rarely upon the neck or scalp. Its etiology is unknown. It 
consists of a hyperplasia of epithelial tissue, the corneal layer 
is thickened, the prolongations of the rete extending further 
into the corium. 

Symptoms. — Senile keratomas begin either as a small yellow- 
ish, reddish, or brownish, dry plaque, or as a slightly elevated 
papillomatous wart. The plaques gradually and slowly increase 
in height and sometimes in size, ranging from the head of a pin 
to a bean or larger ; they are granular or rough to the touch and 
are covered by fine dry or fatty scales. The upper layers of the 
scales are easily removed but the lower layer is closely adherent 
and if removed leaves a bleeding surface, granular and but 
slightly elevated, or even depressed below the level of the skin. 
In advanced cases the keratoma occasionally appear as masses 



SENILE WARTS 233 

of large crusts covered by scales. They may remain unaltered 
for years; sometimes, however, one may spread, the tissue 
becomes indurated, ulcerates, bleeds readily, and assumes the 
character of an epithelioma. 

It is often impossible to determine whether the growth is a 
senile wart or a precancerous keratosis, yet this is of great prog- 
nostic importance. It is safe to say that the wart never be- 
comes malignant except after traumatism, prolonged irritation 
or some such cause as is usually recognized as an exciting factor 
in the causation of epithelioma. The senile keratoma may be- 
come malignant without any known cause. Owing to the ex- 
treme rarity of epithelioma following warts, this prognosis can 
be virtually disregarded, while in keratoma it must be kept in 
mind. The differential diagnosis is therefore of importance not 
alone on account of the prognosis but also on account of the treat- 
ment, warts requiring virtually none, while keratoma on account 
of the possibility of its transformation into a malignant growth 
should be treated as soon as recognized. Diagnostic points are 
the location, the origin, and the presence or absence of scales. 

Treatment. — Keratomas should be removed. This can 
sometimes be accomplished by inunction with a 50 per cent, 
resorcin ointment, but its action is slow. More rapid and more 
effective is radiotherapy, the usual method of treatment to-day. 
If the growth becomes malignant total extirpation by the knife 
is necessary. 

Cornua Cutanea. — Cutaneous horns are growths which on 
account of their prominence have been called horns. They 
may be of the nature of warts or keratoma, but start most 
frequently from a plaque of the latter. The surface, consisting 
of the horny layer of epithelium, is hard, the interior is soft, 
either fatty, or friable fasciculi composed of cells of the rete. 
The cornua filif orme is a thin warty growth sometimes found on 
the eyelids. It is from 5 to 10 mm. in length, i to 2 mm. in 
diameter, and is of no importance. The ordinary form is to be 
treated as a keratoma. 

SENILE WARTS 

Senile warts are among the most frequent dermal affections 
of old age, occurring mostly after the fiftieth year and increasing 



234 PATHOLOGICAL OLD AGE 

in number with advancing age. Their etiology is unknown but 
it is supposed to be due to some perversion in the normal 
senile degeneration of the rete mucosum. There is a hyper- 
plasia of the rete, the prolongations projecting downward into 
the corium, the papillae extending upward into the excrescence 
produced by the rete and its epithelial covering. 

Symptoms. — Senile warts are soft, flat, pigmented and usu- 
ally of a granular appearance. They generally range in size 
from a pin's head to a bean, but occasionally they are much 
larger. They are round or irregular in shape and usually ex- 
tend but little above the surface of the skin. The apex may be 
smooth or finely granular, occasionally coarsely granular or rough 
and the whole growth may be closely adherent to the skin, like 
a plaque, or attached by a broad neck, rarely by a thin pedicle. 
The wart can be removed by a sharp spoon or by the finger nail, 
leaving a granular bleeding surface which is soon repaired. The 
favorite location for senile warts is the back, but they may occur 
upon the chest, neck, abdomen, occasionally on the face, scalp, or 
extremities. Occurring on the face or on the dorsal surface of 
the hands, they may be senile keratoma instead. (See Senile 
Keratoma.) 

Treatment. — The senile warts sometimes disappear without 
treatment. If their removal is desired, any of the ordinary 
mechanical or medicinal caustics can be employed, care being 
taken not to injure the surrounding skin. 

ROSACEA 

The rosacea of Jadassohn is the disease usually described as 
acne rosacea, not the simple rosacea in which there is telan- 
giectasis without seborrhea. Rosacea is a senile disease since 
it rarely occurs before the forty-fifth year. 

Etiology. — The cause is unknown. It occurs most fre- 
quently in those who use alcohol to excess and it is often found in 
those suffering from digestive disorders. It also occurs occa- 
sionally in women during or after the climacteric. 

Pathology. — Rosacea is a hyperplasia of the sebaceous glands 
with retention of sebum, and dilatation and anastomosis of the 
surrounding capillaries. An inflammatory or pustular acne 
eruption and comedones appear frequently as a complication. 



ROSACEA 235 

Symptoms. — Rosacea appears most frequently about the 
nose, occasionally on the cheeks, chin or lips, rarely elsewhere. 
It begins with a pinkish erythema gradually getting darker and 
later minute blood-vessels are seen ramifying over the surface 
The surface feels greasy and the dilated openings of the seba- 
ceous glands are capped by particles of dust. A minute mass or 
string of sebum can be expressed. In the second stage of the 
disease papules or nodules arise from the erythematous surface. 
These range from a pinhead to a pea in size, are firm, dark, 
painless and present minute tortuous blood-vessels. In some 
cases the nodules grow to the size of a walnut, in rare cases they 
become still larger forming rhinophyma tumors. These may 
be single or multiple, round, lobulated or pendulous masses, 
dark red in color, painless, but producing a conspicuous deform- 
ity. According to Kaposi the rosacea nose of the wine drinker 
is bright red, of the beer drinker cyanotic or violet, of the liquor 
drinker it is dark blue. 

Treatment. — The underlying cause must first be removed if 
possible. Of special importance in internal medication is the 
cure of gastric and intestinal disorders. The local treatment 
must meet two indications, the cure of telangiectasis and of 
the glandular hyperplasia. The former condition can be some- 
times relieved by hypodermic injection of a tenth (i/io) per. 
cent, solution of adrenalin, or by the local inunction of an oint- 
ment of the same strength. If this fails, either the negative 
galvanic current may be used as in the treatment of hyper- 
trichosis, or a fine thermocautery, or the knife slitting the vessels. 
Operative work about the face of the aged is often followed by 
worse disfigurement and sometimes by ulcers and cicatrices 
which may develop malignancy. Gottheil recommends in the 
early stage of the disease a mild sulphur lotion and internally 
ichthyol in i- or 2 -grain doses after meals. Zeller recommends 
that the lesion be painted with the tincture of the chloride of 
iron twice daily for five days or until a thick crust is formed and 
considerable inflammation results. Sulphur ointment is then 
applied until the inflammation disappears when the painting 
with iron is to be repeated. Zeissel claims to have cured cases 
by this procedure. An effective means for diminishing the 
glandular enlargement is by the use of tannic acid. The surface 
is first thoroughly washed with alcohol, then pencilled over with 



236 PATHOLOGICAL OLD AGE 

a solution of tannic acid. Resorcin is sometimes effective. 
For the tumor growth radiotherapy has given the most satis- 
factory results. 

DERMATOSES WITH MINOR MODIFICATIONS IN OLD 

AGE 

Eczema 

The various chronic eczemas are of frequent occurrence ; the 
acute form appears seldom, and then mostly about the genitals 
and lower limbs after scratching. The disease is more tenaceous 
in the aged, the itching is more severe, the scale and crust 
formations are more profuse. The acute hyperemia, diffuse 
edema and serous exudation are less pronounced but there is 
frequently a sero-sanguineous or purulent sanguineous discharge 
with intense pruritus. In many cases the eczema follows scratch 
lesions and eczema intertrigo is frequently met with in the aged. 
The eczema following scratches appears usually as linear hemor- 
rhagic lesions which may leave small ulcers or if situated over 
veins they may cause phlebitis or thrombosis. After the crusts 
disappear their site is marked by grayish or brownish lines. 
The diagnosis of eczema in the aged is simple. The most fre- 
quent type, eczema rubrum, presents the typical symptoms, 
redness, swelling, infiltration, exudation and crusting with pruri- 
tus. When occurring as a linear lesion following scratching it 
might be mistaken for herpes, but the latter disease occurs only 
as large vesicles following a nerve trunk or the area of its distribu- 
tion, it IS painful, and the pain is persistent remaining sometimes 
for months after the vesicles disappear. If itching is present 
we must determine whether it is a senile pruritus or due to this 
disease. (Zoster senilis is a far more serious disease and will 
be considered separately.) Impetigo contagiosa may simulate 
eczema but is rare in the aged, it occurs as discrete vesicles and 
the crusts appear as if stuck upon the skin. The vesicular 
type of eczema may be mistaken for erysipelas, dermatitis 
venenata or syphilis, but the history will generally suffice to 
clear up the diagnosis. 

Acne has no itching, the infiltration is usually limited to the 
sebaceous glands and comedones are found among the pustules. 

Dermatitis is generally of traumatic origin, occurs suddenly 



ECZEMA 237 

and subsides upon removal of the cause. Simple erythema, due 
to hypermia, has no exudation. Where exudation does occur it 
is always an eczema. In herpes febrilis the vesicles are grouped 
about mucous outlets and occur during febrile affections. 
Lichen rubrum is rare in the aged and it can be readily differ- 
entiated from eczema by the dilated orifices of hair follicles 
when the scales covering the papules are removed. Psoriasis, 
also rare in the aged, may be mistaken for papular eczema after 
scale formation takes place, but the defined contour, abundance 
of shiny scales, absence of moisture and single type of lesion 
should clear up the diagnosis. The presence of senile pruritus 
sometimes makes the diagnosis difficult. This must be ex- 
cluded. 

Treatment. — In the treatment of eczema and in almost all 
dermatoses of old age, we find some difficulties that are not 
present in earlier life. The skin being dryer and surface circu- 
lation poorer, drugs are not absorbed as readily, they are not 
as active, the healing process is slower and irritants are liable 
to produce necrosis and gangrene. The epidermis being thinner 
and dryer is readily rubbed off, leaving an excoriated surface 
which becomes a good field for pathogenic germ propagation, 
hence the frequency of purulent and erysipelatous infection. 
The uncertainty of the underlying cause in most dermatoses 
necessitates generally a purely empirical method of procedure. 
In some cases regulation of the diet will effect a cure, in 
others protection from exposure to dust or water will suffice, 
in still others internal medication is required; sometimes a 
dermatosis will disappear without treatment, in other cases 
nothing apparently helps. In the treatment of eczema the 
cause should be determined if possible and eliminated. This 
can usually be done if there is a local cause, as scratching, 
intertrigo, vocational irritation or a parasite. If no cause can 
be discovered attention must be paid to the ordinary dietetic 
and hygienic rules and we must depend upon the local medi- 
cation. Water should be excluded except in the inflammatory 
stage when clothes dampened with a weak solution of lead or 
aluminum acetate can be used. After the inflammatory stage 
has passed an alcoholic solution of 1/4 per cent, of thymol 
should be applied for an hour several times daily while in the 
intervals, the surface should be covered with zinc stearate. 



238 PATHOLOGICAL OLD AGE 

Other drugs that are of service in some cases are zinc, lead 
and bismuth salts, white precipitate, ichthyol, tar, pyrogallol, 
sahcylic acid, sulphur, etc., in powder or ointment. Radio- 
therapy, massage, and other mechanical measures have been 
tried with occasional succes. 

Pityriasis tabescentium, in which fine scales of dried epithe- 
lium can be rubbed or scratched off the skin, is a normal senile 
condition, not a disease. Other forms of pityriasis are ex- 
tremely rare in the aged. Prurigo senilis is described by Pic as 
"La maladie cutanee la plus commune chez de Viellard est le 
prurigo." On the other hand Jadassohn declares that the true 
prurigo, prurigo Hebrae, does not occur in the aged and is further- 
more a rare disease at any period of life. 

Psoriasis when occurring in the aged is usually carried over 
from earlier life and does not differ essentially from the earlier 
disease. The scaly formation may be less profuse and the lesions 
may be lighter in color and occasionally there is itching, prob- 
ably a local senile pruritus. In the treatment, which is purely 
empirical, irritating drugs must be avoided. 

Dermatoses due to mechanical, chemical or thermic causes 
occur in the aged less frequently than in earlier life, the aged 
being less exposed to them. Corns, bunions, hammer toes and 
other pedal defects are frequently found and present no difficulty 
in their diagnosis. Bedsores occur frequently and may become 
gangrenous. The diagnosis is simple. 

Burns are far more serious in the aged on account of their 
constitutional effect and the slow local regeneration. Atten- 
tion must be paid to the heart and kidneys apart from the local 
indication. 

Pernio is rare. Dubreuil described a form of chronic senile 
pernio occurring in the aged, not accompanied by bullas or ulcers 
but by circulatory disturbances which become pronounced with 
the advent of cold weather and gradually disappear in the 
spring. The parts affected become tumefied, irregulaily marked 
with dark red or violet marbling, and are numb. During the 
height of the symptoms the parts are intensely painful, swollen 
and dark. This condition is, however, rare. 

Vocational dermatoses are infrequent and present no marked 
difference from such conditions in maturity. Toxic dermatoses 
probably constitute the majority of senile dermic affections 



BACTERIAL DERMATOSES 239 

but the etiology of many is still disputed. It appears certain 
that the same toxic cause may produce various lesions and dis- 
eases and the same disease may be due to a variety of causes, 
toxic or non- toxic. It is consequently impossible to make a 
definite classification of toxic dermatoses except where the 
etiology is positively known, such as urticaria and erythema 
multiforme, dermatitis herpetiformes, pemphigus, etc. Parasitic 
dermatoses are infrequent in the aged, perhaps because they are 
less exposed, or less hairy, or because the senile skin is a poor 
field for their propogation. When they do appear they do not 
differ from the diseases of maturity. Pediculi vestimentorum 
occur occasionally among the same class as in maturity, but do 
not present any difference. Parasitic disease may be mistaken 
for senile pruritus, and the scratching may result in eczema. 
Mycoses are rare in the aged and do not differ from the mycoses 
of matiuity. A body favus is occasionally seen shortly before 
death where there had been a prolonged cachexia, as carcinoma, 
tuberculosis, etc. Jadassohn believes it is due to an abnormally 
located mycelium growth. 

Bacterial dermatoses occur rather frequently. (The most 
important of these, erysipelas, will be treated among the infec- 
tious diseases of the fifth group.) The pyodermatoses are seen 
occasionally either as primary affections or secondary to other 
diseases, the latter sometimes predominating over the original 
disease. The streptogenic dermatoses appear in two forms, 
impetigo contagiosa and ecthyma. The true impetigo conta- 
giosa does not occur in the aged but a mild vesicular eruption 
of streptogenic origin is occasionally found as a complication of 
other dermatoses. These present superficial vesicles which 
rupture, forming transparent yellowish crusts, and produce no 
constitutional effect. Ecthyma occurs occasionally as a second- 
ary disease in pruritic affections. It is probable that the mild 
impetigo is the outcome of a non- virulent strain of streptococci, 
while ecthyma is the result of a virulent strain of these germs. 
The latter may begin as a vesicular eruption, soon becoming 
pustular, or it may begin with pustules which, after rupture and 
drying, produce opaque yellow scabs. They are more deep 
seated than the other and may cause ulcers. Local antiseptics 
are indicated. The staphylo genie dermatoses generally attack 
the glandular orifices and tubes, producing inflammation and 



240 PATHOLOGICAL OLD AGE 

abscess. The sudoriparous glands are apparently immune 
from attack in the aged, but the sebaceous glands and hair 
follicles are occasionally the seat of inflammation from this 
source. More serious affections due to staphylococcic infec- 
tion are boils and carbuncles. The simple folliculitis super- 
ficialis consists of numerous small pustules upon an inflamed 
base. It follows local irritation with infection, gives little 
distress and may persist for weeks or months if not treated. 

Furuncles may follow a folliculitis as an extension of the 
pyogenic process, or it may begin as a more intense and exten- 
sive folliculitis or a perifolliculitis. In this as in all pyogenic 
affections of the skin there must be a peculiar state of the system 
to furnish a suitable field for the existence and development of 
the germs. This is found in diabetes, nephritis, gastric or 
intestinal disorders causing autointoxication, circulatory dis- 
eases, etc. Diabetes especially favors the production of fur- 
uncles and carbuncles. 

Carbuncles are virtually deep-seated furuncles of large size in 
which the integument is undermined and several sacs are formed. 
These sacs hold pus which makes its way to the surface through 
one or several openings. There are usually grave constitutional 
symptoms present. In simple folliculitis antiseptic lotions or 
ointments and the observance of dietetic and hygienic rules 
generally effect a cure. If crusts have formed these must be 
removed. In furunculosis the treatment of the cause is of 
primary importance. If it is a chronic disease like diabetes or 
nephritis there may be successive crops which must be dealt 
with. Occasionally internal medication with arsenic is of 
service. Serum (vaccine) therapy has given brilliant results 
when used at the onset of the disease but after the boil has 
developed it is useless, as the slough must be removed before 
healing can be effected. A furunculosis vaccine is on the 
market with reports of remarkable results in furuncles and 
boils. Furuncles can sometimes be aborted if the cause can be 
rapidly eliminated. If due to autointoxication following con- 
stipation, active catharsis is sometimes effective and this is the 
rationale of magnesium sulphate treatment, which is occasion- 
ally curative. If this fails, excision or the cautery becomes 
necessary. Carbuncles must be treated like boils, but if the 
vaccine therapy fails, other abortive measures are futile. The 



TUBERCULAR DERMATOSES 24I 

cautery or the knife should be used early to allow free discharge 
of the pus and the slough should be picked out with a forceps. 
The injection of carbolic acid is intensely painful and may pro- 
duce extensive necrosis. The constitutional symptoms of 
septic infection as well as the causative condition must not be 
neglected. 

Tubercular dermatoses occur seldom in the aged and then 
generally as some form of lupus. The senile lupus does not 
differ from the lupus of earlier life. Beginning as a well-defined 
slightly elevated patch, light brown in color, and about the size 
of a hemp seed, or slightly larger, it increases very slowly in 
size, while the center becomes depressed. The top is covered 
with glistening epithelial scales. It may remain small through- 
out life, or it may increase to the size of several inches in di- 
ameter, it may remain indolent for years or it may expand more 
rapidly, invading the deeper tissues and' becoming nodular and 
ulcerous at the top, or it may develop into an epithelioma. In 
cases originating in old age the lesion is often formed rapidly 
while the further progress is slow. 

Earlier lupus erythematodes may suddenly become active 
and progress to suppuration or to tissue destruction. In 
some cases favorable involution and scar formation ensues. 
The favorite location of lupus is the face ; occasionally it appears 
upon the scalp, rarely upon the hands, feet, or other portions of 
the body. The forms met with in the aged are the lupus 
erythematodes, lupus vulgaris, and lupus vulgaris erythematoides 
(Lenoir), an intermediate form. The scrofuloderma are rare 
in the aged and are almost always associated with glandular 
or bone tuberculosis. Jadassohn describes a tuberculosis fungosa 
serpiginosa which appears to partake of the character of both 
lupus and the scroftiloderm. This occurs most frequently in 
the lower extremities in connection with bone or gland tubercu- 
losis. In many cases there are fistulous openings from the under- 
lying lesions and near their openings serpiginous plaques form. 
These are soft, dark red, irregular patches, which grow rapidly 
and spread, while their centers form scars. Yellow miliary macules 
as a result of colloid degeneration are sometimes found in the 
scar tissue. The tuberculides may be mistaken for syphilides or 
malignant growths. Where the diagnosis rests between tuber- 
culosis and syphilis if the history is insufficient, it may be neces- 



242 PATHOLOGICAL OLD AGE 

sary to resort to the tuberculin and Wasserman tests in order to 
obtain the etiological factor. The history, and the slow prog- 
ress of the tuberculides will distinguish them from malignant 
growths. The treatment includes the constitutional treatment 
for tuberculosis and local treatment of the lesion. The Finsten 
light, radiotherapy and the cautery are the most effective 
methods of treating the local condition. The older methods 
by inunctions are seldom used, since the mechanical measures 
are so much more effective. Where a tuberculous affection is 
due to an underlying lesion, such as a bone or gland tuberculosis, 
the latter must be cured before the dermal lesion can be 
improved. 

Lepra may occur in the aged but it does not differ from the 
same disease in earlier life. 

Angioneuroses are sometimes observed in the aged but they 
do not differ from the diseases of earlier life excepting one 
form of herpes called zoster senilis. In this the symptoms are 
much more severe and prolonged than in the ordinary herpes 
zoster, the disease is more deeply seated, the vesicles are in- 
creased in number and size and they frequently become trans- 
formed into pustular or hemorrhagic lesions. In some pustular 
cases the pustules ulcerate, in others they form crusts which 
leave persistent cicatrices. The hemorrhagic form disappears 
leaving a deep pigmentation or a scar. The pain is intense 
and may persist for months after the lesion has disappeared. 
Secondary cutaneous diseases sometimes follow. 

In the treatment of zoster senilis the relief of pain is the 
first indication. Cocaine in 2 per cent, solution or ointment is 
the most effective local measure, but the relief is only temporary. 
Orthoform, ointments, antipyrin injections, heat, cold, have all 
been tried and occasionally give relief; frequently they have 
no effect. The internal treatment is equally unsatisfactory. 
The usual antineuralgic measures help in some cases and ag- 
gravate the condition in others. In many cases morphine be- 
comes necessary. In this as in other neuroses of uncertain 
origin drugs and other therapeutic measures must be used 
empirically, employing each long enough to observe an effect, 
either physiological or therapeu tic. If beneficial we will naturally 
follow up that treatment, but if detrimental we must go to the 
opposite class of drugs or other measures. 



DERMAL GLANDULAR DISTURBANCES 243 

It is sometimes possible to determine the etiological factor; 
in such cases the elimination of that factor is of first importance. 
Other forms of herpes as well as urticaria and simple erythema 
do not differ from the same diseases in earlier life. They occur 
in old age under the same conditions and require the same treat- 
ment. The progressive nutritional disturbances are infrequent. 
Most of the hyperkeratoses have a congenital basis and, while 
diseases of earlier life, they may persist until old age. They 
generally disappear as a result of the senile changes of the skin. 
Hyperpigmentation and hypertrichosis occur as a primary con- 
dition but they present no difficulty in their diagnosis and are 
of no importance except possibly from a cosmetic standpoint. 
Scleroderma is rarely seen in the aged. 

The retrogressive pathological changes in the skin are 
mostly variations of the normal senile atrophy. Some, like 
diffuse idiopathic atrophy, acrodermatitis atrophicans, xeroderma, 
etc., are extremely rare; others like cutis laxa, stricB, vitiligo, 
etc., are unimportant and require no treatment, while alopecia 
and canites have been discussed. 

The epidermolyses, the pemphigus group, dermatitis herpeti- 
formis, and epidermolysis bullosa heredita are infrequent at any 
time of life and rare in old age. When they do occur they do 
not differ from those of earlier life. 

Dermal glandular disturbances occur frequently. The sudori- 
parous glands are subject to hyperidrosis, anidrosis and bromid- 
rosis (which have been discussed), miliaria and hidrocystoma. 
The latter are retention cysts, bluish and about the size of a 
pin head, forming in the epidermal opening of the sweat glands. 
They occur most frequently on the face of elderly women who 
work in hot rooms. When they perspire the perspiration fills 
these minute cysts which then become elevated above the sur- 
face of the skin. Upon rest in a cool place they disappear. 
Miliaria appears in the aged as a simple vesicular affection of 
little importance. It is identical with the prickly heat of chil- 
dren. Diseases of the sebaceous glands with the exception of 
rosacea are comparatively infrequent. Seborrhea oleosa and 
sicca occur almost exclusively in the form of rosacea. Come- 
dones and acne are rare, although an acne eruption does occa- 
sionally occur in women about the time of the climacteric. 
An artificial acne may be produced by the staphylococcic inf ec- 



244 PATHOLOGICAL OLD AGE 

tion of a folliculitis induced by irritating substances such as 
depilatories, face washes, tar ointment, etc. It disappears if 
the cause is removed. The acne sclerotisans nuckcB, a follicu- 
litis sometimes becoming pustular, is occasionally seen about 
the neck as a chronic condition carried over from maturity 
The pustules may be opened but there is no certain method of 
curing this condition. It sometimes gradually disappears. 
The sycosis non-parasitoria is probably the same condition oc- 
curring in the beard. Other forms of acne occur occasion- 
ally, but they do not differ materially from the diseases of 
maturity. 

CHRONIC ULCER 

Chronic ulcers, especially upon the legs, are frequently met 
with in the aged. They are generally due to some slight trau- 
matism, a blow, bruise, or scratch, which on account of the poor 
surface circulation does not heal readily. A chronic ulcer may 
also be due to a ruptured varicose vein. An ulcer occurring 
upon a previously healthy skin or upon a keratoma or other 
growth is generally malignant in spite of its chronic course. 
It is important before instituting treatment to determine 
whether the lesion is a simple ulcer, a malignant ulcer or a 
syphilitic or tubercular lesion. These all may look alike, run 
a chronic course, gradually enlarging and producing no distress 
until a sensory nerve is involved. The simple chronic ulcer 
begins within a few days after the initial lesion, whether bruise, 
scratch or rupture of a vein. The traumatic lesion does not heal, 
a crust may form while the ulcer below it persists. If there is a 
bruise, an abscess may form which will open and leave an 
ulcerated base. There is usually a serous exudation, or if 
infected the exudation becomes seropurulent or purulent, rarely 
serosanguineous. The ulcer grows in extent, becomes^slightly 
deeper, and has sharply defined but not indurated or everted 
edges. It is painless unless a sensory nerve is involved but 
there is often itching around the margin. The syphilitic ulcer 
can generally be eliminated by the history of infection, the 
primary lesion and the presence of other lesions. The tuber- 
cular form may give a tubercular history, it originates in a 
tubercle which breaks down, its advent is slow and when ulcer- 



CHRONIC ULCER 245 

ating there is little or no pus, thus differing from the ulcer 
following a bruise. The malignant ulcer has usually a history 
of a preceding growth or of scar tissue. The simple chronic 
ulcer does not produce constitutional symptoms unless it be- 
comes infected, and giving no local distress it is often neglected, 
perhaps for years. If infected, the constitutional symptoms 
may become grave, while the excessive amount of pus may 
cause exhaustion. In the treatment of these cases care must be 
taken to avoid giving the patients pain. We must also remem- 
ber that granulations will not start in disorganized tissue, 
however clean we may get it. The surface must be both 
healthy and clean. The ulcer is first washed with warm water, 
then a solution of peroxide of hydrogen is applied until bubbling 
ceases, then warm water must be used again to wash away the 
H2O2. After we have a clean surface a 5 per cent, solution of 
cocaine is applied followed a few minutes later by a caustic, 
either chromic acid or carbolic acid or nitrate of silver and 
washed clean again. The ulcer is then filled or covered with 
lanoline. The following day the washing must be repeated and 
after applying the cocaine the slough is removed by forceps or 
by the knife. An active hyperemia is necessary to initiate 
healthy granulation and a mild hyperemia is required to keep 
it up. Without a sufficient supply of circulating blood these 
chronic ulcers will not heal. Small dry cups or the application 
of hot dry or moist cloths will generally bring enough blood to 
the surface to produce the required hyperemia, for the starting 
of granulations. But no granulations will form if the surface is 
covered with any substance which disorganizes tissue, there- 
fore if caustics or even but a mild bichloride solution has been 
used the surface must be washed clean and if necessary abraded. 
A nuclein should be used as a dusting powder to stimulate granu- 
lations and the ulcer should be packed with an animal fat pref- 
erably anhydrous lanoline. If this method is followed the 
ulcer can be cured, providing there has been no infection. 
Should pus continue to flow in spite of such repeated wash- 
ing showing a more extensive or a general infection, serum 
treatment may be necessary before local treatment will be 
effective. 

{Note* — Nuclein containing sugar of milk is intensely ir- 
ritating.) 



246 PATHOLOGICAL OLD AGE 

NEOPLASMS 
Benign Growths 

Of the benign growths, warts, nevi and fibromata are the 
most frequent ones in old age. (Senile warts and senile seba- 
ceous nevi, have been described.) It is probable that the senile 
sebaceous nevi are really adenomata. Nevi are almost without 
exception carried over from earlier life, persist unaltered and 
aside from their unsightliness produce no distress. Nothing 
need be done for them. Fibroma occur frequently and may ap- 
pear in numbers upon the neck and upper part of the chest, 
less often upon the face or extremities. When small they may 
lie entirely beneath the skin or project slightly as circumscribed 
nodules or plaques; when larger they appear as buttons or 
become pendulous. They vary in size from a pea to a mass 
weighing several pounds, are covered with normal skin, pro- 
duce no distress and if left alone they will remain unaltered 
after they have reached the limit of their growth. Small 
pedunculated growths can be clipped off and the pedicle cau- 
terized. Sessile growths should be left alone unless their size 
or location makes removal advisable. The surgical procedure 
for their removal depends upon the preference of the surgeon. 
Electrolysis, radiotherapy, galvanocautery, thermocautery or 
the knife can be employed. Lipoma like fibroma is seen 
in the aged, often as small pendulous tumors. They resemble 
fibroma but are softer, more regular in shape and generally 
appear singly or in groups of two or three, rarely in numbers. 
Keloid and xanthoma are rare and when occurring are generally 
carried over from earlier life. Keloid may, however, follow a 
traumatism. Other benign growths like hard warts, mollusc a 
contagiosa, condylomata, etc., rarely or never occur in ad- 
vanced age. In dealing with benign growths it must be borne 
in mind that in some cases they become malignant and that 
their transformation into a malignant growth sometimes takes 
place after operation. Better results are apparently obtained 
by the X-ray and Finsten light than by the knife. Radium 
therapy is still too uncertain and too limited in its distribution 
to be more than an experimental measure and the same applies 
to carbonic acid snow. Thiosinamin, fibrolysin and scarlet 
red have given good results in some cases and fail completely 
in others. 



MALIGNANT NEOPLASMS 247 

MALIGNANT NEOPLASMS 

The most important of the maHgnant growths in the aged 
is the epitheHoma. It would serve no purpose to discuss the 
numerous theories that have been advanced to explain the 
etiology and pathogenesis of cancer. There are also diverse 
classifications based upon structure, clinical manifestations, 
tissue involved, primary or secondary appearance, etc. The 
primary dermal epithelioma originates as a dermal lesion; the 
secondary growth is due to an underlying cancer as of the 
breast, or is an extension from a cancer in some neighboring 
tissue as from a cancer of the vagina, or it is a metastatic lesion 
carried by way of the lymphatics or blood-vessels. 

The primary epithelioma is, in most cases, secondary to 
another affection of the skin. Bond says "the complex cell 
change that we associate with cancer has been built up by vari- 
ational changes from the normal type and that one of the stages 
passed through is represented by the various forms of benign 
growth." 

Epithelioma appears clinically in two types, a superficial, 
mildly malignant, extremely chronic type, and the other deep, 
active, and rapid. There is no sharp dividing line between 
the two, and the disease may begin as a superficial chronic 
lesion which after existing for years suddenly becomes actively 
malignant. 

The active form may find its seat primarily upon apparently 
healthy tissue or recent trauma or upon the site of a lupus, 
syphilide, leucoplakia, crural ulcer or scar, rarely upon a senile 
keratoma or xeroderma. It usually begins as a hard light 
colored nodule gradually becoming dark red, irregular in shape 
and but slightly above the level of the skin. There is generally 
a hyperkeratosis and sometimes a papillomatous growth of 
the nodule. A few weeks or months later the surface becomes 
eroded and beneath it there is a raw granular or papillomatous 
stirface which in some cases becomes ulcerative, in other cases 
there is a more or less rapid growth of the papillomatous tissue 
which soon extends beyond the surface and forms the classical 
"cauliflower growth" of malignant papilloma. In this form 
of epithelioma the morbid vegetation may reach the size of a 
hen's egg. It is usually spongy, warty and exudes a foul- 



248 PATHOLOGICAL OLD AGE 

smelling clear or sanguineous fluid. After a time fissures spread 
through the mass, it becomes ulcerative and the whole mass 
turns into a foul ulcer, penetrating the tissues and expanding 
on all sides. In cases where the tissues break down and become 
ulcerated from the start, the further progress is the same as in 
the papilloma. The ulcer presents a hard, overhanging border 
which is undermined and from which a semiliquid mass con- 
taining epithelial cells can be expressed. The epithelioma can 
extend through the tissue perforating and destroying muscle, 
fascia and even bone. In some cases the ulcer exudate forms 
a crust which becomes hard and completely hides the destruc- 
tive process underneath. This form of epithelioma becomes 
painful from the moment that the skin is eroded and the pain 
becomes intense if the surface is irritated. It bleeds readily 
and the surface is necrotic. As the disease progresses the 
neighboring lymphatic glands become involved, later there are 
metastatic cancerous ulcers, cachexia appears and the consti- 
tutional symptoms follow. 

The mild superficial epithelioma usually finds its seat upon a 
senile keratoma. This may exist for years before it is noticed that 
there is any change in its size or character. In some cases there 
is nothing more than a small superficial nodule perhaps covered 
with scales, or a hard crust covering an excoriation or an ulcer 
produced perhaps by scratching or by a slight blow. This may 
persist for years without change, or other small nodules may 
form about the site of the original lesion. Sooner or later the 
nodules break down and become ulcerated, the ulcers being at 
first shallow and small but gradually extending and in some 
cases rapidly destroying the underlying and surrounding tissue. 
The rodent ulcer thus formed is at first painless, later it becomes 
intensely painful. Occasionally the destructive process halts 
and after remaining quiescent for years starts afresh or the 
ulcer heals. This form of epithelioma rarely involves the 
glands and produces neither cachexia nor other constitutional 
symptoms. 

The favored location of the deep epithelioma is the face, 
mouth, lips, genitals and anus, while the mild epithelioma is 
generally found in the upper part of the face about the eyes or 
nose. 

Paget 's disease of the nipples and most epitheliomata found 



SARCOMA 249 

in other parts of the body are secondary to underlying or con- 
tiguous carcinomata. A class of malignant growths which 
begin in soft nevi are sometimes classed as epitheliomata, 
sometimes as sarcomata. When arising from pigmented nevi 
the growth is pigmented producing the melanotic carcinoma. 
It follows the course of the deep epithelioma, being rapid in its 
onset and development and speedily involving the lymphatic 
glands. 

The lentigo maligna of Hutchinson begins as a darkly pig- 
mented macule which after years of quiescence suddenly begins 
to give evidence of active malignancy and within a short time 
acts as an active epithelioma. 

The diagnosis of epithelioma is often difficult, as there are 
several dermatoses presenting similar clinical manifestations 
without the histological characteristics, while the histological 
characteristics of the former have been found in benign growths. 
The diagnosis depends upon the occurrence of both the clinical 
and the histological findings. A positive tuberculin or Wasser- 
man test does not exclude a coexisting carcinoma. The only 
tuberculide giving similar symptoms is lupus. This occurs 
earlier in life, is generally composed of a group of lesions and 
the border of the ulcer is never indurated or everted. The 
syphilides present a multiplicity of lesions, they do not spread, 
are not painful and improve under the usual treatment for the 
disease. The benign tumors must be diagnosed by the histo- 
logical findings. Sarcoma is more rapid in its development, 
occurs earlier in life, rarely ulcerates and involves neighboring 
tissue or produces metastatic lesions of the same variety. As 
a last resort, if the diagnosis is still doubtful, the microscope 
must decide. 

Sarcoma 

The sarcomatous growths are relatively rare in the aged. 
The sarcoma is a perversion of connective-tissue cell growth 
occurring under circumstances very much like an epithelioma. 
The growth proceeds, however, much more rapidly. It begins 
as a small nodule several of which appear in the same locality. 
By increase and confluence they form tumors, sometimes as 
large as a hen's egg, and may appear on any part of the body. 



250 PATHOLOGICAL OLD AGE 

They are often pigmented and painful, sometimes vegetations 
appear upon them, occasionally they ulcerate. They may be 
secondary to sarcoma in another part of the body, or primary, 
beginning upon the site of a traumatism or other skin lesion, 
rarely upon a healthy surface. They present various forms, 
may be hard or soft and show under the microscope charac- 
teristic round, spindle-shaped or giant cells. While not exhibit- 
ing the local destructive tendencies of active epitheliomata, 
metastases are more frequent, extirpation is followed by recur- 
rence with increased virulence and the constitutional effects are 
pronounced. 

Atypical forms of epitheliomata and sarcomata are occasion- 
ally seen in the aged, but a particle clipped from the growth and 
examined under the microscope will generally determine its 
character. 

Treatment of Malignant Growths. — There is probably no 
pathological condition in which more therapeutic experiments 
have been made than in malignant growths. About everything 
known to have a caustic or other destructive action upon animal 
tissue has been used to destroy malignant growths, while in- 
ternal medication has kept pace with external measures. We 
have found, however, no better method of dealing with such 
growths than total extirpation by the knife. Various measures 
have been employed to bring about the destruction of the 
growth, yet none of them has been generally accepted. Some 
still adhere to chemical caustics, others prefer to use the knife. 
Among the newer measures are radium emanations, the X-ray, 
high-frequency Herzian waves, Finsten light fulguration and 
Forest's cold cautery. Each has its supporters, each has 
accomplished a more or less complete destruction of the growth, 
yet none has absolutely prevented the metastases, the involve- 
ment of any neighboring glands or the recurrence of the growth. 
At the present moment the tide is turning toward internal 
medication, the latest method of treatment being chemotherapy. 
It is sought to obtain "a chemical substance which, admin- 
istered by the mouth, shall exhibit affinity for the peculiar 
chemical constitution of the cancer cell. Granting that this 
affinity produces a result injurious or destructive to the growth, 
there at once ensues a cure of cancer" (Morton). So far this 
has not been accomplished. In the treatment of epithelioma 



SENILE PSYCHOSES 25 1 

Judd reports about 90 per cent, of cures by the X-ray but in 
the other 10 per cent, especially in old persons, the X-ray, 
"while it caused destruction of the growth, failed to prevent its 
almost immediate recurrence." Korbl reports that of seventy- 
three cases that were re-examined after X-ray treatment, 
thirty-seven had a recurrence of the growth. Moullin, Finzi and 
Dominici reporting upon the result of radium treatment gave 
few favorable results. The object is always to destroy the 
growth and as long as the growth is a purely local condition 
without gland or constitutional involvement, the simple caus- 
tics like chloride of zinc, caustic potash or soda, acid nitrate of 
mercury, lactic acid, etc., will suffice. Arsenic is still the most 
popular of this class of drugs, although its action is apparently 
not that of an escharotic but of a toxin to the pathological cells. 
The great danger in local arsenic medication is arsenical poison- 
ing through absorption. This can hardly be prevented, a weak 
solution or paste being useless. We must, therefore, use it in a 
strength of at least i per cent, to be effective. This, if used for 
a long period, produces toxic symptoms and the treatment must 
be discontinued or replaced by the use of escharotics. For deep 
growths the only reliable treatment is early and complete exci- 
sion. Some surgeons go further and excise neighboring lym- 
phatic glands. Even this generally fails, if the growth is a 
sarcoma, as metastatic growths almost invariably follow. At 
present we have no means of combating this form of growth and 
all that can be done is to destroy the growths as they appear, 
relieve symptoms and maintain the strength of the individual. 
It is only in the superficial forms of epithelioma that we may be 
reasonably certain of effecting a permanent cure. In the 
deeper lesions, especially after glandular involvement, operative 
intervention may give temporary relief, but it rarely prevents 
a return of the disease. The one imperative rule in all cases 
is to remove the growth completely as soon as its character is 
established. 

SENILE PSYCHOSES 

Psychic disorders occur frequently in the aged. Senile de- 
mentia is by far the most prevalent, being in many cases second- 
ary to other disorders, and generally the terminal stage of all 



252 PATHOLOGICAL OLD AGE 

mental diseases that are carried over from eariier life. The pri- 
mary apathetic senile dementia occurring as the end result of the 
normal senile degeneration of the brain and of cerebral softening 
has been described under those heads. Secondary forms are 
described by some authorities as agitative senile dementia 
occurring during or following mania, paranoiac, melancholic, 
hypochondriac, etc., senile dementia. Other forms of senile 
dementia are due to traumatism, apoplexy, or arteriosclerosis, 
and the terminal dementias of other psychoses. In the second- 
ary dementias the primary psychosis gradually becomes milder 
in its manifestations while the intellect becomes duller and 
duller until mentality is completely obliterated. Senile de- 
mentia whether primary, secondary or terminal is progressive 
and incurable. 

Acute senile dementia described by Salgo consists of a rapid 
dementia following acute manifestations of mental impairment, 
dulling of the intellect, incoherence and confusion, loss of 
memory, etc., with constant restlessness. These are accom- 
panied by visceral disorders, insomnia, and rise in temperature. 
It may clear up or the dementia may become progressively 
deepening. 

Amentia, senile delirium or hallucinatory confusion is occa- 
sionally met with. This generally begins with rapid confusion, 
loss of orientation and great restlessness, followed by illusions, 
delusions, hallucinations and phobias, the patient is excited and 
violently active, with periods of comparative quiet during 
which the mental phenomena are milder and the restlessness 
disappears. There may be delusions of persecution or of 
grandeur, violent outbursts or depression. In many cases the 
reflexes are exaggerated, pupils irregular, there is a weak irregu- 
lar, rapid pulse, fever, constipation, and icterus. Albumin and 
indican are found in the urine. Amentia may terminate in 
dementia, occasionally it is the precursor to a hemiplegia. 
Recovery is rare in the aged. While the violent symptoms may 
abate there is a progressive dulling of the intellect until demen- 
tia is complete. A form of senile delirium sometimes occurs 
during the senile climacteric. 

Hypochondria and melancholia are so frequently associ- 
ated and so intimately connected in the aged that they will 
be considered together. The melancholia may follow a neuras- 



MELANCHOLIA 253 

thenia, psychasthenia or hypochondria or it may be a primary 
condition due to some powerful emotion. Hypochondria also 
may be primary or secondary to a neurasthenia or psychas- 
thenia. There may be emotional depression without impair- 
ment of the intellect or such mental impairment as is usual with 
the normal senile degeneration, but there are always unnatural 
fears, or a haunting anxiety without a definite object. In some 
cases there is a fear of disease, of death or future punishment 
for insignificant misdoings. The hypochondriac is given to in- 
trospection and to self-examination of his physical condition. 
The discovery of an abnormal feature, a macule or papule, a 
slight rise in the rate of respiration or pulse rate will suffice to 
arouse the most agonizing fear of disease, culminating in melan- 
cholia. Slight symptoms are exaggerated and suggestion or 
mimicry will give rise to imaginary symptoms and sensations. 
In some cases it will be possible to explain away symptoms, but 
in most cases the efforts of the physician to quiet the patient's 
fears are looked upon with suspicion. When melancholia super- 
venes it is impossible to make the patient realize the absurdity 
of his ideas and fears, but it is often possible in an early stage of 
melancholia to make him forget them. He will greet the 
physician with numerous complaints and the latter, if tactful, 
will turn the patient's thoughts to other subjects. He will 
forget then his ailments and may, when reminded of them, 
forget their location. 

Senile melanchoha may appear in an apathetic, depressive 
form or in a restless, agitated one. In the apathetic form the 
patient will sit for hours, apparently indifferent to his surround- 
ings, complaining, mumbling or weeping. In the agitated 
form the patient is restless, excited, anxious, fearful, and some- 
times violent. In the violent state he may commit murder or 
suicide. In some cases there are remissions during which the 
patient is comparatively free from the mental and emotional 
depression but each attack leaves the mental faculties more 
impaired and finally the patient sinks into a dementia which is 
progressively deepening. 

Treatment. — In the treatment of senile psychoses we must 
bear in mind the presence of senile degeneration of the brain 
with the certainty of present or ultimate senile dementia. The 
keynote of treatment is psychic stimulation. This is opposed 



254 PATHOLOGICAL OLD AGE 

to the generally accepted method of treating psychoses by seda- 
tives, rest and quiet. When there is much restlessness, warm 
baths should be employed and if these fail we may resort to the 
bromides. Mental confusion is best treated by powerful but 
harmonious sensuous impressions which will attract and hold 
the patient's attention. An old familiar air will sometimes dis- 
pel the confusion and this is one of the most effective means for 
stimulating memory and quieting an excited patient. It is 
often possible to reason with a patient while his mind is so 
diverted. In some cases the conversion of the subject of an 
hallucination into the reality, unknown to the patient, will 
restore reason. A patient who nightly saw a ghost at the foot 
of his bed was cured of this hallucination when one of his 
friends suddenly appeared at the foot of the bed, covered with 
a sheet, then threw off the sheet and spoke to the patient. 
Sometimes a powerful impression will destroy an illusion, 
delusion, hallucination or phobia. The following is a typical 
example. The patient aged sixty-nine who had been an ardent 
fisherman in his earlier years, was suffering from arthrosclerosis 
of the ankles and shoulders. He had been treated for chronic 
rheumatism, but the condition grew worse and he feared that 
his joints would all grow stiff and he would become like the 
ossified man he had seen in a museum. From this fear he de- 
veloped the dread that he would become a burden to his 
family and that they were anxious to get rid of him. He then 
developed the apathetic form of melancholia. Some of his 
friends took him then upon a fishing boat and a line was placed 
in his hands. At first he was indifferent to his surroundings until 
there was a sudden tug upon his line. He was startled for a 
moment but as soon as the line was passing through his hand he 
grasped it and pulled in his fish. He continued fishing and 
returned home in a cheerful spirit and cured of the melancholia. 
Notwithstanding the benefit of change of environment and 
the constant attention of physicians and nurses, incarceration 
in an asylum is perhaps the worst possible treatment for senile 
psychoses. The association of the senile dement with other 
insane persons will not improve him mentally but may produce 
mental perversion in addition to mental weakness. Such patients 
need constant diversion and mental stimulation, not rest and 
quiet. Mental agitation requires stimulation of a different sort 



MODIFIED PSYCHOSES 255 

and the more intense the excitement the more intense the stimu- 
lation must be. A brass band playing a loud patriotic air will 
attract attention where a violin solo will have no effect; the 
harmonious movements of a large ballet will quiet the mind 
while the confused movements of dancers in a ball room will dis- 
concert and irritate the patient. A large well-drilled chorus 
presenting pleasing stage pictures will relieve melancholy and 
depression and will calm mental agitation by substituting 
another form of mental stimulation. Aural stimulation, espe- 
cially by old familiar airs, is more effective than visual 
stimulation unless the latter can be prolonged and the interest 
maintained. The stimulation may be prolonged until brain 
fag sets in when the patient will fall asleep. Medication must 
have the same purpose as the psychic measures, mental stimu- 
lation. The only drug suitable in these cases is phosphorus 
given in i/50-grain doses three times a day. 

MODIFIED PSYCHOSES 

General paresis is rare in the aged. When it does occur it 
does not give the clearly defined clinical picture that it presents 
in maturity and it may be mistaken for senile dementia. In 
general paresis in the aged the delusions of grandeur are less 
florid than in maturity, but they appear early and thereby dis- 
tinguish this disease from senile dementia. There may be 
delusions of grandeur in the delirious form of senile dementia, 
but these are generally combined with unsystematized delusions 
of persecution, phobias, and weakened intellect. General 
paresis in the aged develops more rapidly but the apoplecti- 
form attacks occur less frequently than in maturity. There is 
the same difficulty in the speech, which is rapid and irregular, 
the patient sometimes hesitating, at other times tripping, run- 
ning one word into the next without a break between them, or 
suppressing words or syllables. The paresis and paralysis of 
the extremities occur at irregular intervals and clear up partially, 
but each apoplectiform seizure leaves the patient mentally and 
physically weaker than before. There is no known treatment 
for this condition. 

Mania is rare except in the maniacal outbursts of delirious 
senile dementia, in the form of a few monomanias peculiar to 



256 PATHOLOGICAL OLD AGE 

the aged, as oikeiomania, and in circular insanity. There are 
generally delusions of grandeur and morbid impulses arsing there- 
from, the latter being often immoral or criminal. There is a 
disregard of consequences to others and of retribution or punish- 
ment to himself. Mental agitation is pronounced. Mania in 
the aged sometimes disappears for months, sometimes reappear- 
ing without apparent cause and in a more aggravated form. 
Some cases are succeeded by amentia or dementia. Mania 
alternating with melancholia and lucid intervals characterize 
circular insanity. Such cases are occasionally met with in 
melancholia when some insignificant mental or physical irri- 
tation will cause a maniacal outburst sometimes lasting for 
days, followed by exhaustion. During this period the mind 
is apparently clear but mental depression follows and the cycle 
is resumed. In rare cases the melancholia follows mania, the 
latter following a clear period. There is frequently a history 
of early mental disorder, hysteria, neurasthenia or other neuro- 
sis. Senile paranoia with delusions of persecution occurs fre- 
quently, yet it is seldom recognized. In most cases the sense 
of hearing is lessened and the patient, realizing his diminished 
usefulness, becomes suspicious when conversation which he 
cannot hear is conducted in his presence. This gives rise to 
delusions of persecution, the patient fearing that those who have 
the charge of looking after him are anxious to put him out of the 
way. Delusions of smell and taste arise from the fear of being 
poisoned and auditory and visual illusions develop from other 
fears. The patient exaggerates his own importance until his 
ideas about himself assume the shape of delusions of grandeur 
and while boasting of his strength and ability to stand pain, 
he will complain of the intense pain associated with insignificant 
hurts. In some cases this is due to the desire to arouse sympathy, 
generally, however, to hypochondria. 

When the fear of persecution is directed to a member of 
the family there is generally a substantial basis which in itself 
is trivial, such as momentary absence, food too hot or too cold 
or too salty, a sharp reply or reproof, etc. The patient broods 
over this, exaggerates its importance, and develops suspicion 
and hatred, fear is aroused and this is converted into delusions 
of persecution. The fear that his enemy may kill him if he 
utters any complaints will prevent the patient from expressing 



SENILE PSYCHAStHENIA 257 

his fears and the first intimation of the patient's mental condition 
may come when his will is read. The tactful physician will 
often be able to obtain the confidence of his patient sufficiently 
to elicit paranoiac delusions, although he will not be able to 
remove them. A querulent form of paranoia is met with 
occasionally after the senile climacteric and as mental de- 
cadence proceeds the complaining and whining gradually give 
way to a mumbling dementia. 

SENILE PSYCHASTHENIA 

Psychasthenia or mental exhaustion is generally associated 
with neurasthenia. Owing to the failure to differentiate be- 
tween the two conditions, psychasthenia is usually considered 
as the cerebral phase of neurasthenia. Psychasthenia may, 
however, exist without nervous exhaustion or weakness but will 
give symptoms of the latter. When the impulses originating 
in the brain are weakened they are carried more slowly and with 
less force, by the nerves and thus the nervous symptoms are 
produced. Occurring in the aged it presents slight differences 
from the similar condition of maturity. 

Etiology. — Psychasthenia is due to excessive mental activity 
with insufficient repair and to the probable absorption of the 
waste products of mental activity. It occurs most frequently 
in those engaged in exciting mental work, especially where rapid 
action or mental concentration is involved, hence we find it 
frequently in professional men, writers, ministers, physicians, 
and scientists, in those who must calculate and reason quickly 
as brokers and others engaged in buying and selling without 
long deliberation, in bookkeepers, etc. It occurs generally 
when there has been a period of intense mental activity follow- 
ing a period of rest. After mental deterioration has begun in 
the aged, even slight excitement will suffice to produce brain 
fag and if this excitement continues brain exhaustion may 
result. 

Symptoms. — The symptoms can be divided into three stages, 
a preliminary stage, a stage of brain fag and a stage of brain 
exhaustion. 

During the preliminary stage the mind is in a state of ten- 
sion. Ideas whirl or fly through the brain and the individual 
17 



258 PATHOLOGICAL OLD AGE 

cannot express himself fast enough. If he writes he omits the 
last letter of the word or he omits words altogether. He makes 
errors in calculation by overlooking figures, errors in speech by 
chopping off words and phrases. He does not take time to 
deliberate where deliberation is necessary, forms extravagant 
projects, losing the sense of time and space. In this period he 
is in a state of mental erythrysm. The stage of brain fag 
then sets in rapidly. It begins with mental confusion and head- 
ache. The brain feels as though covered with a blanket that 
will not let ideas through. Ideas do not come readily and pro- 
longed mental concentration becomes impossible. The mind 
wanders to other subjects and an effort to keep it concentrated 
upon any one thing causes a confusion of ideas. He cannot 
keep out other thoughts, while the main subject becomes dim 
and may be forgotten. This stage resembles senile impairment 
leading to dementia, but the psychasthenic can still evolve grand 
conceptions, while in senile impairment this is impossible as 
the ideas run along a lower plane. If the mental faculties are 
employed during the stage of brain fatigue or brain fag, and 
strong efforts are made to continue the mental labors, the stage 
of brain exhaustion is reached. In this condition thought is im- 
possible and the patient is really in a state of mental collapse. 
During the second stage the will becomes weakened and cere- 
bral impulses become slower and weaker and are conducted less 
forcibly by the nerves. The functional activity of the nerves 
becomes diminished but not from lowered functional capacity, 
as is the case in true neurasthenia. In the aged psychasthenia 
hastens the senile degeneration of the brain and it is a powerful 
factor in causing early senile dementia. 

When psychasthenia and neurasthenia occur together they 
may be mistaken for general paresis. This disease is rare in 
old age, convulsions may appear and there is generally a feeling 
of exhilaration while in the other there is mental depression 
and phobias, instead of delusions of grandeur. 

Treatment. — Mental rest is the most important factor in the 
treatment of psychasthenia. While in neurasthenia mental 
stimulation is indicated to dispel the depression, in psychas- 
thenia physical exercise which does not required mental ex- 
ertion must be employed. If there is at the same time mental 
depression, it will be necessary to resort to mental stimulants 



1 



SENILE NEURASTHENIA 259 

like phosphorus, small doses of morphine, cannabis indica, etc., 
beside hygienic measures, such as change of environment, out- 
door sports, preferably hunting and fishing with a cheerful com- 
panion. The use of aphrodisiacs recommended in the mental 
depression of neurasthenia is contraindicated in psychasthenia, 
since the latter is usually followed by senile dementia in which an 
abnormal recrudescence of sexual desires frequently occurs and 
gives rise to sexual perversions. 

SENILE NEURASTHENIA 

The term neurasthenia is applied loosely to a number of 
symptoms arising from constant and excessive brain and nerve 
fatigue. The term should be applied only to the condition of 
nerve weakness and not to the mental depression that accom- 
panies it and is usually due to it, nor to the purely psychic 
phenomena of mental exhaustion which are described as psychas- 
thenia. This psychasthenia is responsible for many symptoms 
that are also found in neurasthenia. Both conditions, neuras- 
thenia and psychasthenia, frequently exist at the same time. 
Neurasthenia in the aged presents some peculiarities due to 
the generally diminished functional capacity and activity. 

Etiology. — Neurasthenia is due to excessive nervous activity 
with insufficient repair and in addition probably to an auto- 
intoxication from the absorption of waste products arising from 
nerve activity. We find a similar condition when muscle is 
employed after fatigue sets in. A local toxemia makes further 
activity difficult and finally impossible. When this point is 
reached we get muscle exhaustion. In neurasthenia the point 
of complete nervous exhaustion is rarely reached as the mental 
depression and psychasthenia prevent further nervous activity 
as soon as nerve fatigue is felt. Under some extraordinary 
impulse the neurasthenic is able to exhibit some nervous energy, 
which would be impossible in complete exhaustion. 

Nerve weakness generally follows prolonged excitement 
whether of business or pleasure, with improper recreation or 
insufficient exercise. It does not occur in those engaged in 
physical labors unless the character of the work necessitates 
frequent responses to sudden nerve impulses. The telegraphic 
operator waiting for orders which must be instantly transmitted, 



26o PATHOLOGICAL OLD AGE 

the telephone switch board operator, the type writing operator, 
and all who must be on the alert for work requiring rapid action, 
are liable to neurasthenia. In the aged such nerve tension 
causes rapid nerve weakness and the symptoms appear early 
since the realization of advancing age is itself depressing, caus- 
ing introspection and the recognition of failing powers. The 
sense or feeling of weakness is exaggerated, while under a proper 
stimulus the aged person will exhibit remarkable nervous 
energy. Predisposing factors are heredity, alcoholism, early 
excesses, worries and other causes of mental depression, dis- 
turbed circulation, toxemias and arteriosclerosis. The nervous 
or neurotic disposition in which there is excessive nervous 
irritability is the underlying factor found in most cases. It is 
very rare in females. 

Symptoms. — In the aged the symptoms of neurasthenia are 
always accompanied by mental depression and the latter is 
frequently more marked than the nervous symptoms. In 
many cases the mental depression which ensues as the result of 
the recognition of the waning mental, physical and sexual 
powers, causes a diminution of will and energy and the aged 
person exaggerates his loss of power and nervous energy. This 
pseudoneur asthenia is a form of malingering. If there is a real 
neurasthenia present there will be the intention, but not the 
impulse to perform the intended act. The patient feels con- 
stantly tired and even the slightest task is performed under 
protest. Where he had been previously mentally alert and 
physically active he is now dull and apparently lazy. His 
movements are sluggish and are performed with an effort. A 
sudden danger will rouse him to activity but he soon relapses 
into a state of mental and physical depression. Neuroses of 
various organs are often found. Nervous dyspepsia is gener- 
ally present, with anorexia, thirst, gastric and intestinal indiges- 
tion, constipation, while diarrhea occurs upon slight emotional 
excitement. Cardiac neuroses are frequently observed and 
vasomotor disturbances may occur. In spinal neurasthenia 
there is a feeling of weakness along the spine and tender points 
are found upon pressure along the spinal column. Other 
nervous symptoms occasionally observed are neuralgia, paras- 
thesia, fine tremors, etc. Headache or hemicrania is some- 
times present and various disorders of the special senses may 



SENILE NEURASTHENIA 26 1 

occur. In the senile cases it is often difficult to decide whether 
some of the symptoms are due to neurasthenia or to arterio- 
sclerosis or to other senile changes. The mental symptoms 
are irritability, depression, introspection, phobias, etc. The 
aged patient watches his pulse and notes every change in fre- 
quency or rhythm, he observes his breathing, his skin, etc., 
indeed his mind is centered upon himself and the minutest 
change causes him to fear the worst. The morbid depression 
and fear of death lead to hypochondriasis which later resolves 
itself into a melancholia, this terminating in dementia. 

Senile neurasthenia is a serious condition as there is gener- 
ally a cerebral arteriosclerosis present which cannot be cured, 
its symptoms are persistent, and the mental state tends to 
melancholia and dementia. If psychasthenia coexists with 
neurasthenia the depression soon gives way to senile dementia. 

Neurasthenia can be divided into four stages, an irritable 
period preceding the period of fatigue, the stage of nerve fatigue, 
the period following fatigue and preceding exhaustion and the 
stage of exhaustion. During the preliminary period the indi- 
vidual exhibits physical irritability. Like the man with his 
finger on the trigger waiting for the command to fire, the patient 
is ready to jump or start upon the slightest provocation. He 
does things rapidly when there is no necessity for speed, makes 
unnecessary movements and is in a state of nervous tension. 
In the stage of fatigue, he moves slowly and with deliberation 
and avoids unnecessary activity. In this stage mental depres- 
sion appears and tends to inhibit motion. There is still some 
irritability with occasional outbursts of speed or exaggerated 
energy. If this is persisted in the stage of fatigue is followed by 
the intermediate period. Now it requires a sensible effort and 
a strong impulse to arouse nervous energy. In this stage the 
local neuroses appear, introspection becomes marked and we 
find the host of symptoms described. The stage of complete 
nervous exhaustion is rarely reached. In this stage there is 
complete loss of energy, motion and even eating becomes an 
effort. It may occur if under some powerful stimulus during 
the preceding period some extraordinary effort is made. This 
stage ends in collapse. There is no sharp dividing line between 
the stages, the first passing rapidly into the second, the second 
passing slowly into the third. The onset of the last may be 



262 PATHOLOGICAL OLD AGE 

sudden. Aged persons generally seek medical aid when the 
stage of fatigue sets in; younger individuals make efforts to 
continue their work until this stage is well advanced. 

Treatment. — The most important indication in the treat- 
ment of senile neurasthenia is to improve the mental condition. 
This can be done most effectively by the use of aphrodisiacs 
and a favorable result will have a more potent beneficial effect 
upon an aged man than any other stimulus. Change of 
scene, mental diversions, hobbies, out-door amusements, are 
all beneficial. There must, however, always be a cheerful 
companion to prevent a lapse into the habit of introspection. 
A day's fishing when fishing is good will rouse nervous energy 
and dispel mental depression, while quiet, rest, and the compan- 
ionship of fellow sufferers in a sanitarium will not cure mental 
depression or neurasthenia. For the physical condition we 
can use strychnine, caffeine or arsenic, salt water baths and 
static electricity. Pleasurable excitement which will keep the 
mind occupied but will not confuse should form part of the 
routine treatment. There is probably nothing more effective 
to take the mind away from thoughts of the body than an old 
familiar air. 

Insomnia, especially insufficient sleep at night, is not alone 
distressing; it invariably causes introspection with phobias. A 
hot bath or foot bath should be tried, hot malted milk taken 
before going to bed and if these fail we must give veronal or 
trional in 5- to lo-grain doses. .,, 

I 

SENILE EPILEPSY 

Senile epilepsy is a disease of old age only in so far as the 
ordinary epilepsy of earlier life may occur in the aged. Cases 
originating in old age present minor clinical differences, but as 
these differences are ascribed to a coexisting arteriosclerosis 
some authorities speak of it as arteriosclerotic or cardiovascular 
epilepsy. 

Etiology. — While neither the etiology nor the pathology has 
been determined, in nearly every case one of the supposed causes 
of early life can be found. It may be an infectious disease, 
intoxication or autointoxication, powerful emotion, sexual 
excesses, traumatism or some cerebral disease. In some cases 



I 



SENILE EPILEPSY 263 

no cause can be assigned and these are called idiopathic senile 
epilepsy. It is probable that in every case there is an irritation 
of some portion of the cerebral cortex which contains a focus left 
from some former cerebral disease. The irritation may come 
from blood toxins as in alcoholism, syphilis, nicotine or tubercu- 
losis or from traumatism or a sudden emotion, etc. It is uncer- 
tain what the relation between senile epilepsy and arterioscle- 
rosis is, but it is generally conceded that the vascular condition 
may produce the neurosis. 

Symptoms. — Senile epilepsy possesses the pathognomonic 
element of suddenness. The first attack is generally as severe as 
later ones. The cry is frequently absent, but there are occa- 
sional premonitory symptoms, as headache, spasms, neuralgic 
pains, vertigo and frequently an aura. The convulsions are 
generally less severe and not as prolonged as in maturity. In 
other respects the convulsive seizure does not differ from that of 
maturity. The mind is, however, frequently affected and after 
several attacks dementia is liable to set in with progressive loss 
of mentality. It is hardly possible to mistake epilepsy for any 
other disease having convulsions. The convulsion of uremia is 
generally followed by coma and there is a history of renal dis- 
ease. In apoplexy there is paralysis, meningitis is very rare in the 
aged and there is generally some paralysis, headache, mental dis- 
turbance, fever, irregular pupils, etc. Hysteria is rare in the aged 
and there is generally a history of daily attacks with emotional 
perversions, the attack ending in a flood of tears. In general 
paralysis, the disturbance of speech and the mental condition 
will serve to distinguish it. 

Epileptiform convulsions can be produced by interfering 
with the cerebral circulation, as when compressing the carotids. 
In these cases there are clonic spasms but no aura, no cry, 
the sphincters are not relaxed, coma comes on gradually, there 
is no deep sleep after the attack and there is no mental impair- 
ment. In senile epilepsy the tonic spasm lasts but a moment, 
the clonic spasms are weaker, the legs are not 'thrown about 
as in younger life, and the sleep is less profound than in 
maturity. 

Treatment. — The treatment is as in maturity. The under- 
lying cause must be treated. If no cause can be found we must 
fall back upon the bromides, preferably the bromide of strontium 



264 PATHOLOGICAL OLD AGE 

in lo-grain doses several times a day with total exclusion of 
meat. The nerve stimulants like strychnine are contraindicated. 



Neuroses in the Aged 

The aged frequently present nervous phenomena for which 
no cause or pathological change can be found. 

(Some of these like epilepsy and neurasthenia present marked peculiarities and 
are placed among the modified diseases. Others like senile tremor and senile 
abasia are probably manifestations of senile changes of the cord and are classified 
accordingly, while under senile neuroses will be placed various neuralgias and 
other neuroses that are rare or unchanged.) 

Hysteria is extremely rare in the aged and does not differ 
from the same disease in maturity. Cases may be carried over 
from earlier life or follow traumatism, the latter cause producing 
at times extreme depression and any of the numerous manifesta- 
tions of hysteria. Large doses of bromides and narcotics may 
be required to quiet the patient. In giving narcotics in these 
cases they should be combined with respiratory and cardiac 
stimulants. 

Hemicrania or migraine is of rare occurrence in the aged and 
is then usually carried over from maturity. It is really a dis- 
ease which becomes milder and finally disappears with advancing 
years and when it does occur it is either a symptom of cerebral 
arteriosclerosis or a prodromal symptom of some serious cere- 
bral or nervous disturbance. It may precede apoplexy or 
mental breakdown. When occurring as a prodromal symptom 
it is usually associated with irritability, anxiety, nausea, vertigo 
and other nervous phenomena. The treatment depends upon 
the cause. For the relief of the headache, a large dose of bro- 
mide of sodium should be taken and if the heart is in good con- 
dition this may be combined with one of the coal tar prepara- 
tions like antipyrin or acetphenetidin with caff ein or ammonium 
carbonate. 

Chorea is rarely met with in the aged although choreiform 
convulsive movements of the hands are sometimes seen in the 
course of other nervous diseases especially in those of traumatic 
origin. Very few cases of the chronic Huntington's chorea have 
been reported and these were invariably associated with senile 
dementia. The ordinary chorea appears generally in a mild 




Tremorgraph — Chorea. (Xeustaedter, Med. Record, July 17, 1909.) 




Tremorgraph — Epilepsy. (Neustaedter, Med. Record, July 17, 1909.) 




Tremorgraph — Hysterical tremor. (Xeustaedter, 
Record, July 17, 1909.) 



Med. 



y 



INSOMNIA 265 

form, is sometimes limited to one side and the movements may- 
be rhythmical. A one-sided chorea has been observed preceding 
a hemiplegia. The choreic movements are identical with the 
same movements seen in childhood. The treatment consists 
in the administration of arsenic in increasing doses until the 
physiological effects of the drug are produced. Chronic chorea 
is not benefited by arsenic or any other drug. 

Diabetes insipidus is sometimes classed as a neurosis, al- 
though it is in almost every case a symptom of a nervous or 
cerebral affection. It occurs most frequently in connection 
with hysteria, epilepsy and neurasthenia, follows apoplexy or 
traumatic affections of the brain or cord and may be a temporary- 
condition following some strong emotion. The aged sometimes 
complain that they pass an excessive amount of urine when 
suffering from dilatation of the bladder. They have then a 
frequent desire to urinate and pass a small amount each time 
but the total amount is not excessive. 

The treatment of diabetes insipidus depends upon the causa- 
tive disease. 

INSOMNIA 

The aged frequently complain of insomnia, although in most 
cases it is a pseudo-insomnia for which nothing need be done. 
They take frequent naps during the day and are then unable 
to sleep more than a few hours at night. Slight exercise induces 
fatigue and they fall asleep after their meals and after doing a 
little work. Mental exercise brings on brain fag and they fall 
asleep while reading the paper, listening to a lecture or sermon 
or after an argument or dispute. In this way the aged indi- 
vidual may get three or four hours sleep during the day and his 
night's rest being broken perhaps by an overdistended bladder, 
he complains of insomnia. To cure this pseudo-insomnia it 
would be necessary to prevent the daylight naps, which aside 
from being a harsh procedure, would interfere with recuperation 
and repair. The best that can be done in these cases is to draw 
off the urine and give a hot drink and a hot foot bath at night. 
They will fall asleep more readily and will not be disturbed by 
an irritable overfilled bladder, but it will not increase the total 
amount of sleep. Drugs are unnecessary in this condition. 



266 PATHOLOGICAL OLD AGE 

Real insomnia may be due to pain, fever, toxemia, nervous 
or cerebral disease. There may be inability to fall asleep, 
broken sleep or insufficient sleep. The treatment depends upon 
the cause. If hypnotics are required they should be selected 
from the carbamide group, not from the methane or chloral 
group of hypnotics. 

NEURALGIA 

Various forms of neuralgia occur in the aged, trifacial neu- 
ralgia being the most frequent and the only one for which a 
conclusive etiological factor has been found. (This is described 
in the second group.) 

Trifacial neuralgia may be due to other causes than compres- 
sion of the terminal fibers in the bony substance of the lower jaw. 
In most cases it is secondary to another local disease as caries 
of the teeth, disease of the mucous membrane of the nose, max- 
illa, or frontal sinus, exostoses, or it may be secondary to an infec- 
tious disease, or it may be due to cold, local irritation, etc. In 
some cases no cause can be found. The differentiation of the 
affected branches of the trifacial nerve depends upon the loca- 
tion of the painful pressure points. In supraorbital neuralgia 
this is found in the supraorbital notch of the frontal bone, in 
supramaxillary neuralgia it is found in the infraorbital fora- 
men, and in infra maxillary neuralgia the painful pressure point 
is at the mental foramen. These points are surrounded by 
painful areas. The pain is severe, there being usually a con- 
stant dull ache in the region of the affected nerve branch with 
paroxysms of agonizing sharp pain over the painful pressure 
points. In the treatment of trifacial neuralgia the cause should 
be determined and, if possible, removed. Supraorbital neu- 
ralgia may be due to disease of the frontal sinus, while many 
cases of supramaxillary and inframaxillary neuralgia are due to 
dental caries. Where the cause is unknown or cannot be 
removed the treatment must be directed to the relief of pain. 
The injection of lo minims of a 4 per cent, solution of cocaine 
will generally give temporary relief. Relief and sometimes per- 
manent cure is obtained by alcohol injections. Other local 
measures are morphia and atropia injections, the application of 
a piece of cotton soaked in ether, the ethyl chloride spray. 



NEURALGIA 267 

cocaine ointment, galvanism and heat. In extreme cases when 
local measures fail surgical interference including resection of the 
nerve branch may become necessary. 

Occipital neuralgia is rare in the aged. It is generally due 
to sudden exposure to cold, sometimes to gout or arthritis defor- 
mans, rarely to infectious diseases. Painful pressure points are 
midway between the mastoid process and the first vertebra and 
at the posterior junction of the sternocleidomastoid muscle and 
the occipital bone, the pain shooting into the surrounding tissue 
and sometimes extending over the entire scalp. The neuralgic 
paroxysms are intense, lancinating and last but a moment. The 
treatment is purely local and consists of the application of moist 
heat, cocaine ointment, galvanism. It may be necessary to give 
morphine to secure sleep. Surgical intervention is rarely 
necessary. 

Brachial neuralgia may occur in the aged as a result of disease 
of the heart, aorta or subclavian artery, of rheumatism, gout, 
infectious diseases, diabetes, cancer, hysteria or local disease. In 
most cases no etiological factor can be found and the disease is 
classed as a pure neurosis. There are usually several pressure 
points where branches emerge from their muscular folds. Beside 
the paroxysmal attacks there are often local disturbances such as 
paresthesias, herpes zoster, local hyperemia or anemia, these 
occasionally alternating. The treatment is as for occipital 
neuralgia. 

Ischial neuralgia occurs occasionally in the aged and is usu- 
ally due to sudden changes of temperature or prolonged stand- 
ing, sometimes to pressure upon the nerve by growths, hard- 
ened feces, etc., sometimes again to local passive congestion, 
inflammations or other causes of neural irritation. Bilateral 
neuralgia may be due to a disease of the cord or to a constitu- 
tional disease. Painful pressure points are found all along the 
ischial nerve and the pain radiates but slightly. Slight at the 
beginning, the pain becomes rapidly more severe with occasional 
paroxysms of intense sharp pains lasting but a moment. Pres- 
sure and motion increases the pain, but the paroxysms occur fre- 
quently at night also. In lying, sitting and standing the patient 
assumes a posture which will shield the affected side from pres- 
sure and motion. The treatment is as for occipital neuralgia. 
In some cases a mixture of equal parts of chloral and camphor 



268 PATHOLOGICAL OLD AGE 

pencilled along the nerve will give relief. Many of the drugs 
useful in neuralgias in earlier life cannot be used in the aged. 
Aconitin is dangerous, iodide of potassium is useless, arsenic and 
quinine are of doubtful value. Alcohol injections are occasion- 
ally of benefit, sometimes they produce a neuritis and local 
tissue inflammation. In many cases we must resort to morphine 
for temporary relief and surgical measures, such as nerve stretch- 
ing or resection. 

PREFERENTIAL DISEASES OF OLD AGE 

The fourth group includes the diseases most frequently 
found after middle age although they may appear earlier. 
Some of these diseases are primary, as diabetes, gout, can- 
cer. The prevalence of these diseases in late life and their 
infrequency in early life would seem to indicate some relation 
to the process of involution. The secondary diseases of this 
group include chronic diseases many of which arise in old age 
from a focus left over from an earlier acute disease. 

CARCINOMA 

Ignorance of the nature and pathogenesis of cancer makes 
it difficult or impossible to assign it to its proper group. It is 
here classed as a preferential disease owing to its prevalence in 
advanced life. If we consider it an infectious disease it would 
be properly placed among the infectious diseases of the fifth 
group. If we accept the view that it is a perversion of the nor- 
mal process of involution of certain tissues we would be obliged 
to assign it to the first group. The latter seems to the author 
to be the most plausible explanation of its origin and nature and 
is in accord with the theory of tissue-cell evolution. Cohn- 
heim's theory is that cancers arise from faulty embryonic devel- 
opment, embryonic cells remaining dormant until late in life. 
The tissue-cell evolution theory is based upon analogy with 
evolution in higher and more complex forms of life. Atavistic 
tendencies appear in all forms of higher life and in all stages of 
evolution. May not the primitive cells show the same tenden- 
cies? These tendencies would become more pronounced at 
that stage of evolution when the cells are departing from their 



CARCINOMA 269 

most perfect condition and their functions are no longer best 
fitted for the welfare of the economy. In senescence, functional 
activity of the cells is lessened, the organism becomes function- 
ally weakened and the tissues are altered. If at this time there 
occurs a cell traumatism or nutritional perversion which inter- 
feres with the steady progressive cell evolution there will be a 
change in the character and properties of that cell. It may 
cause complete destruction of the cell, or further impairment 
of its functions or perverse stimulation and if there are atavistic 
tendencies there will be a return to an earlier type, or to cells 
of an earlier evolutionary period with disordered growth and 
disordered functional activity. Cancer never begins en masse, 
but in a single cell or in several adjoining ceUs possessing similar 
tendencies. Its further growth is by extension from a single 
focus and by the formation of new foci by means of cancer cells 
carried in the blood or lymph channels, these cells stimulating 
cells of other tissues to disordered growth or activity. Cancer 
is not a metastatic disease, i.e., one that shifts its location away 
from the original site. Heredity is probably the most important 
etiological factor in the atavistic tendencies in ceU life, just as 
it is in the life of the human being as a whole. It is impossible 
here to take up all forms of cancer, and all the localities in which 
they may appear, or to go into the pathology of cancer growths, 
therefore, little more than the symptoms and treatment of the 
most important forms will be considered here (the malignant 
growths of the skin being placed among the modified skin dis- 
eases). Syms points out a precancerous stage and shows that 
benign tumors, chronic ulcerations, chronic inflammations, scars, 
and prolonged irritation are prominent precursors of cancer. 
He quotes Young, who demonstrated an immense proportion 
of carcinomas among cases of enlarged prostate; Bloodgood, 
who studied sixty-five cases of pigmented mole which became 
malignant; and Mayo who found between 60 and 70 per cent, 
of gastric carcinomas on the sites of gastric ulcers. The recog- 
nition of this precancerous stage would save many cases from 
the later ravages of cancer. There is apparently an antagonism 
between cancer and the infectious diseases. Cancer is very 
rare in lepers or syphilitic cases or in malarial districts. A 
large percentage of cancer cases never had any infectious disease, 
while on the other hand erysipelas rarely develops in cancer 



270 PATHOLOGICAL OLD AGE 

cases. Tuberculous cadavers show cancer in 4 per cent., non- 
tuberculous cadavers show cancer in 11 per cent, of cases. 

There are certain clinical features common to all cancers. 
The most prominent is the cancer cachexia, a rapid emaciation, 
an anemia with rapid diminution in hemoglobin percentage 
and in the number of red cells and a muddy, sallow complexion, 
loss of strength keeping pace with the emaciation and mental 
depression. Primary cancers are generally followed by second- 
ary ones, the most frequent location of secondary cancers being 
in the lymphatic glands, and where the primary cancer attacks 
an abdominal organ other than the liver, the liver is the usual seat 
of it. Pain is a frequent but not a constant feature. It is usually 
neuralgic in character, and due to pressure of the growth upon 
a nerve or ganglion. It is often more severe and persistent in the 
secondary cancer than in the primary lesion. In many locations 
the growth can be neither seen nor felt but as it increases in 
size it presses upon adjoining tissues and symptoms pointing 
to disease of such tissues appear. This is a late feature. 
Cancer growths near openings have a tendency to grow to- 
ward the opening occluding it, and when in channels or tubes, 
the tendency of growth is inward, causing stenosis with final 
complete occlusion. Cancer does not produce fever. When 
there is fever it is due to an accidental infection or inflammation. 

There is no cure for cancer except complete extirpation of the 
growth by surgical means, before metastases have appeared. 
Even then the relief is often only temporary, as foci for 
future growths have usually been produced. The character 
of the operation will depend upon the findings after the 
growth is reached. Drug treatment can be only palliative. 
Jacobi strongly recommends methylene blue in doses of i 
grain gradually increased to 3 grains three times a day, com- 
bined with extract of belladonna, in inoperable carcinoma. 

Oral Cancer. — Cancer of the mouth includes cancer of the 
lip, tongue, cheeks, tonsil and pharynx. They occur most fre- 
quently in tobacco smokers. 

Cancer of the lip is usually a primary epithelioma having its 
seat at the junction of the mucous membrane and the skin. 
It begins in most cases as a papule or small, hard wart which 
may exist without change for months or years. It then begins 



CANCER OF THE TONGUE AND MOUTH 271 

to itch or annoy and a crust forms. The patient picks this, 
leaving a sHght ulceration which refuses to heal but increases 
in size and depth while the surrounding tissue becomes hard 
and swollen. In some cases the disease begins in a fissure or 
a pustule which later ulcerates. The further progress of the 
disease follows one of two courses. The ulcer may become 
larger and deeper until it destroys a large part of the lip or 
the lip may be filled with a mass of cancerous tissue forming a 
cauliflower-shaped hemorrhagic tumor, which will bleed upon 
the slightest irritation or will crack and become covered with 
foul ulcers. Later the adjoining or neighboring tissues become 
involved. The submaxillary glands are early affected, becom- 
ing hard, swollen and painful, while the other glands of the 
lower jaw and the neck are soon similarly involved. The 
viscera, however, are rarely affected. Cachexia is not marked 
until the disease is well advanced but it then progresses rapidly 
and may cause death from exhaustion. The only disease with 
which cancer of the lip is liable to be confounded is syphilis. 
The history, the presence of other syphilides and the Wasser- 
mann reaction will clear up this source of error. The only 
effective treatment is complete extirpation of the growth before 
glandular involvement. If the glands are affected these also 
must be removed. Delay is fatal. 

Cancer of the Tongue and Mouth. — Cancer of the tongue is 
usually a primary epithelioma beginning as an indurated swelling 
at the surface of the organ. The swelling is painful upon pres- 
sure, neuralgic pains shoot sometimes through it, and the tongue 
can be protruded with difficulty only, while swallowing becomes 
painful. In some cases the swelling increases until the greater 
part of the tongue is involved, in others it ulcerates, the ulcer 
growing larger and deeper until the whole oral cavity is a foul- 
smelling ulcerated mass. The salivary glands swell and may 
ulcerate also. Cachexia sets in early and causes death from 
exhaustion in from three to twelve months. In some cases 
death is due to a deglutition pneumonia. The only treatment 
possible in these cases is surgical. Antiseptic mouth washes and 
local analgesic remedies may be required for temporary relief 
of the fetor and pain, and rectal alimentation may become neces- 
sary. The progress of the disease cannot be halted by medicinal 



272 PATHOLOGICAL OLD AGE 

measures. In some cases the cancerous progress begins in the 
mucous membrane of the cheek as a small ulcer which spreads 
rapidly in all directions, soon involving the tongue. In rare 
cases the ulcer burrows through the cheek. The further prog- 
ress is as in cancer of the tongue. 

The above description applies to cancer of the tonsil also. 
A few cases of primary cancer of the parotid gland have been 
recorded. It begins as a swelling under the angle of the jaw, 
increasing rapidly in size, pressing in all directions and interfering 
with deglutition and occasionally with respiration. The tumor 
itself is not painful but pressure upon nerves causes intense pain. 
It may be mistaken for parotitis but its constant growth with- 
out fever or pain upon pressure will serve to distinguish them. 
Surgical interference is the only remedy. 

Cancer of the Larynx. — This is usually a primary epithelial 
growth; sometimes it occurs as an extension of a carcinoma 
from an adjoining tissue, rarely as a secondary cancer. Its 
favorite seat is upon the vocal cords, though it may occur 
elsewhere. It begins as a surface infiltration which forms first 
excrescences then ulcerations which extend in size and depth. 
It resembles cancer of the rectum in its slow development, slow 
progress, slight cachexia and late involvement of the lymphatics. 
The early symptom of cancer of the vocal cords is a persistent 
hoarseness without pain or cough. The laryngoscope shows 
a broad-based growth which may be smooth or uneven, slightly 
reddened and with an infiltrated area around it or at one side. 
The motion of the affected band during respiration and phona- 
tion is greatly impaired, thereby differing from benign growths 
in w^hich the motility is not altered. Cancer growths in other 
parts of the larynx will produce symptoms of stenosis or pressure 
according to the direction in which the growth extends. It may 
cause difficult deglutition or difficult respiration or pain on 
motion, these symptoms increasing until deglutition or respira- 
tion becomes impossible. When ulceration occurs there is a 
mucopurulent discharge, later, a fetid odor of the breath shows 
necrotic changes. Secondary cancers of adjoining tissues fre- 
quently follow and their symptoms may be more severe than the 
symptoms of the primary growth. 

Treatment is early surgical intervention. 



PLEURAL CANCER 273 

Cancer of the Lung. — Cancer of the lung is very rare and 
most of the reported cases were secondary cancers in which the 
primary one was of greater cHnical importance. Primary cancer 
occurs only by extension of a carcinoma of the finer bronchial 
tubes along the bronchioles and alveoli into the lung tissue. The 
tissue first becomes hard then breaks down in the center while 
the borders extend. Cavities may thus be formed, simulating 
tuberculosis. During the period of hardening the physical 
signs resemble pneumonia. Secondary pulmonary carcinoma 
is usually multiple and very small, simulating miliary tuber- 
culosis. The symptoms are not clear and it is often difficult to 
say whether it is cancer, local tuberculosis, pneumonia, pleurisy, 
miliary tuberculosis or bronchiectasis. There is no fever, rarely 
pain, but occasionally hemorrhage or a hemorrhagic expectora- 
tion, the blood being intimately mixed with mucus. Dyspnea 
with shallow breathing is a constant symptom. In rare cases 
the tumor will cause bulging of the chest wall, or displacement of 
the heart. 

Treatment is entirely symptomatic. Operative procedures 
have been reported but none have ever been successful in the 
aged. Arsenic has been used with temporary success in the 
cachexia and morphine is generally the only means of relieving 
the distressing symptoms. 

Pleural Cancer. — Cancer growths in the pleura are rare and 
almost always secondary. The early symptoms are those of 
pleurisy, later pressure symptoms and pain occur. The cachexia 
is marked, as the disease in the pleura is usually a late affection. 
A rare form of primary endothelial cancer called lymphangitis 
carcinomatodes is peculiar to the pleura. Secondary growths 
occur in the lymph channels and may invade the lungs and bron- 
chi. The early symptoms are those of serofibrinous pleurisy 
without change of the border of dulness upon change of position. 
Puncture produces a serochylous exudate containing epithe- 
lial debris and round, generally polynucleated cells. The 
needle passes through denser tissue than in ordinary pleurisy 
(Schwalbe). The growth is frequently painful, the pain ra- 
diating toward the arm. The pressure upon the lung will 
produce dyspnea and if erosion of blood-vessels occurs there will 
be a hemorrhagic expectoration. This form of malignant growth 
progresses more slowly than other forms of cancer, the cachexia 
18 



274 PATHOLOGICAL OLD AGE 

sets in late and the fatal issue may not be reached until several 
years after the initial symptoms. There is no curative treat- 
ment for pleural cancer. Aspiration may relieve dyspnea if 
there is much exudate and narcotics must be given toward the 
end to relieve pain. 

Mediastinal Cancer. — Cancer in the mediastinum is often 
a primary lymphadenoma of the mediastinal lymphatics, occa- 
sionally secondary to cancer in a neighboring tissue. The 
symptoms are principally due to pressure upon organs or to 
displacement of tissues by the growth. Pain is infrequent but 
there is generally tenderness over the site of the growth. The 
diagnosis must be often made by the pressure symptoms and by 
exclusion. Cachexia sets in early and death is due to either 
exhaustion or asphyxia from pressure upon the trachea or bron- 
chus. The treatment is surgical. 

Esophageal Cancer. — Esophageal cancer is usually an epi- 
thelioma, occurring in the lower third of the tube. In the aged 
the growth generally proceeds upward and into the cavity of 
the tube, narrowing and finally completely occluding the caliber. 
The symptoms are a progressive dysphagia with a sensation 
that the food is stopped at a certain point and powerful efforts 
at deglutition must be made to carry it past the obstruction. 
Another symptom is the cachexia. The growth rarely proceeds 
outward and therefore symptoms of pressure upon other tissues 
are rare. There is occasional pain, never severe, at the point of 
obstruction. Food when regurgitated is covered with mucus, 
sometimes with blood. The neighboring lymphatics are some- 
times involved but death from asthenia generally sets in before 
secondary cancers appear. Esophageal sounds may be used to 
determine the location of the obstruction, but any effort to force 
the sound past that point may cause inflammation or perforation 
and collapse. Perforation through the cancer growth is rare 
however. The only treatment is early operation. In the mean- 
time foods must be given in liquid form until complete stenosis 
has occurred after which rectal feeding must be resorted to. 
Narcotics and cocaine are only of temporary benefit to relieve 
pain but the pain in the aged is seldom severe enough to require 
treatment. 



GASTRIC CARCINOMA 275 

Gastric Carcinoma 

Gastric carcinoma is the most frequent of the visceral 
cancers occurring in the aged. It is usually a cylinder-celled 
epithelioma. The soft encephaloid and the hard scirrhus 
cancers are occasionally found, but the colloid form is rare. 
Writers generally agree that the pylorus is the favored site of 
gastric cancer, but there is considerable difference of opinion as 
to the main etiological factor. Wilson and McCarty of the 
Mayo clinic found that 7 1 per cent, had developed on the base of 
an old ulcer ; French says a history of ulcer or injury is obtained 
in 6 per cent, but fully half of the cases operated upon show 
evidences of previous idcer; while Weinstein agrees that some 
cancers do develop from ulcers, but he rejects the high percentage 
given by Wilson and McCarty. Ewald points out the rarity of 
gastric ulcer in the aged and sees in traumatism affecting the walls 
of the stomach a notable etiological factor. To harmonize 
these diverse views with the prevalence of cancer at the pylorus 
we must believe that most gastric cancers in the aged result 
from the scar of an early latent ulcer. Gastric carcinoma is 
generally a primary cancer and is followed by involvement of the 
lymphatic glands, often by growths in the liver or gall-bladder, 
occasionally in the peritoneum, intestines or other tissues. 
These secondary cancers may produce more disturbance than 
the primary lesion. 

Symptoms. — There are no early pathognomonic symptoms 
of the disease. The rarity of ulcer in the aged disposes of this 
precancerous stage, but when an ulcer exists sudden or rapid 
diminution of free hydrochloric acid and the presence of lactic 
acid, in conjunction with other symptoms, points strongly to 
cancer and is nearly pathognomonic. Weinstein says a sudden 
abrupt onset in a person who had been in perfect health is one of 
the strongest links in the cancer chain, while Cabot declares that 
any type of dyspepsia occurring in a person over forty who had 
had no such trouble before, is strongly suggestive of cancer. 
These statements do not hold good in senile cases, for in most 
cases there is a history of gastric disturbance going back per- 
haps for months before there are any other symptoms of cancer, 
and gastric disturbances of the aged are rather frequent, yet few 
develop into cancer. 



276 PATHOLOGICAL OLD AGE 

The early symptoms depend mainly upon the location of the 
growth. There is generally loss of appetite and a rapidly devel- 
oping cachexia. If the cancer is situated at the fundus, pain, 
nausea and vomiting occur late and the disease progresses more 
slowly than when it is situated at the pylorus. The cachexia 
is associated with a pronounced anemia, the red cells may sink 
to 3,000,000 or less while the hemoglobin may drop to 50 per 
cent, or less. Emaciation sets in early. It proceeds rapidly if 
the cancer is at the pylorus where it interferes with the passage 
of food into the duodenum or if situated at the cardiac orifice 
where it interferes with the passage of food into the stomach. If 
either orifice is completely occluded death from starvation 
soon follows. The skin in cancer cachexia presents a muddy, 
sallow or ocherous hue most pronounced on exposed surfaces, and 
it is usually dry and wrinkled. The secondary group of symp- 
toms — pain, nausea, vomiting — may vary in degree or be absent 
altogether. Pain usually comes on soon after the ingestion of 
food, but it may occur paroxysmally at any time. It is an early 
symptom in cases where a cancer develops upon an existing 
ulcer and a late one if the cancer is at the fundus. The degree 
of pain varies. Nausea and vomiting are usually early symp- 
toms although in the aged vomiting is infrequent and requires 
severe straining. The vomited matter consists of food in various 
stages of digestion, mixed with mucus and sometimes blood. 
Food vomited two or three hours after a meal is usually foul or 
sour smelling. Blood is generally present early but in quantities 
so small that a microscopic or chemical examination may be 
required to determine its presence. The * ' coffee ground ' ' vomit, 
which contains digested blood with the hemoglobin converted 
into hematin, is a late but almost pathognomonic sign of cancer. 
Lactic acid bacilli are generally found in the vomited matter. 
Of the physical signs the most important is the presence of a 
growth, usually at the pylorus, firm, smooth or nodular, and 
generally movable. It rises and falls with respiration and in 
the aged, who generally have wasted abdominal muscles, it 
can be grasped during expiration. A growth at the fundus, 
usually found at the lesser curvature is not palpable. The 
involvement of the lymphatics confirms the diagnosis of cancer 
in doubtful cases. While there is not a single pathognomonic 
sign of early gastric cancer (except the very rare occurrence of 



INTESTINAL CANCER 277 

cancer cells in the vomitus) and each individual sign and symp- 
tom may be found in some other condition, there are almost 
invariably several symptoms which taken collectively are con- 
clusive of cancer or serve to exclude other conditions. The 
diseases which might be mistaken for gastric cancer are ulcer, 
chronic gastritis, benign growths, cancers outside of the 
stomach, and pylorospasm. The discovery of dissolved albu- 
min in the stomach contents an hour after taking the Ewald 
test meal is pathognomonic of advanced gastric cancer. 
Benign growths in the stomach are very rare, and the tumor 
of pylorospasm will usually disappear. Ulcer and gastritis 
can be excluded by the history and the examination of the 
stomach contents. 

Treatment. — The certainty of a fatal issue without operation 
and the possibility of a cure or at least the prolongation of life 
by operation justifies operative procedure in every case, however 
hopeless the outlook may be. Drugs, except for the relief of 
distressing symptoms, are useless. In senile cases especially, 
early operation is imperative and drug treatment may not even 
relieve symptoms unless given in toxic doses. The only indi- 
cations for drug treatment are to relieve the pain, nausea and 
vomiting, while awaiting the operation. The most effectual 
drug for these symptoms is cocaine in i/8-grain doses. Mor- 
phine and other opiates still further diminish the motility of 
the organ, prevent peristalsis and weaken the respiratory cen- 
ters. Theoretically food given with acidulated pepsin and 
predigested foods ought to be beneficial; usually, however, they 
are of small service, as little is absorbed from the stomach, and 
where a pyloric stenosis exists little if any finds its way into the 
duodenum. The main advantage derived from these foods is 
less likelihood of fermentation. If the vomited matter smells 
sour resorcin, salol or the sulphocarbolates can be given. Hemo- 
globin, manganese and arsenic may be administered to improve 
the anemia, although they are rarely of much service. If the 
cancer is at the cardiac orifice drugs and food must be given in 
liquid form. Rectal alimentation is of service for a few days, 
but it is impossible to introduce sufficient food that way to 
completely nourish an individual. 

Intestinal Cancer. — Nearly two-thirds of all intestinal 
cancers occur in the rectum. Sutton says that 75 per cent. 



278 PATHOLOGICAL OLD AGE 

occur in the rectum and 2 5 per cent, occur in other parts of the 
large intestines. Rectal cancers are, as a rule, mild in their 
symptoms, progress slowly and cause comparatively little dis- 
turbance until far advanced. Secondary cancers occiu* late and 
the cachexia is rarely as pronounced as in cancers elsewhere. In 
many cases the symptoms of pressure upon adjoining tissues are 
more marked than the other symptoms and signs of a growth. 
Pressure upon a nerve or plexus will produce neuralgic pains, 
while pressure upon a vein will cause varix or edema. There 
are no pathognomonic symptoms of a non-palpable cancer. A 
cancer in the sigmoid or rectum can usually be seen through a 
colonoscope and a rectal cancer can usually be felt, by digital 
examination, as a hard, ulcerating mass. Growths in other 
parts of the intestines can sometimes be felt through the flaccid 
walls but it is necessary to eliminate first tumors of the liver, 
kidney, stomach and spleen. 

The early symptoms of intestinal cancer are irregular stools, 
sometimes constipation, at other times diarrhea, sometimes 
hard, at other times soft or watery stools, sometimes copious 
then again scanty, and almost always containing traces of blood. 
Mummery says small frequent urgent stools indicate rectal 
cancer. If the cancer is above the cecum the blood is mixed with 
the stool, if below the cecum it covers the stool. There is flatu- 
lence and borborygmus, sometimes colicky pain but more often 
an ache in the region of the lesion with a painful spot over the 
growth. The diagnosis, however, is never assured until the 
growth is palpable. Other diseases liable to be mistaken for 
intestinal cancer in which no tumor can be felt are chronic 
ulcerative enteritis, syphilis, tuberculosis, concretions and ac- 
tinomycosis. The last one is very rare, while syphilis and 
tuberculosis can be determined by serum tests. Concretions will 
disappear under a brisk cathartic and chronic ulcerative enter- 
itis has diarrhea with pus and shreds of mucus in the feces. 
As the cancer increases it diminishes the caliber of the bowel and 
finally causes complete stenosis with the symptom of intestinal 
occlusion. The treatment is surgical. In no other form of 
cancer is the surgical prognosis as favorable as in rectal cancer. 
Without operation the prognosis is fatal. The only drug indi- 
cations are for the relief of pain and constipation. If the opera- 



CANCER OF LIVER ^ 279 

tion is delayed until secondary cancers form or until complete 
occlusion has occurred, recovery is doubtful. 

Cancer of Liver. — Hepatic cancer is almost always secondary 
to gastric cancer, cancer in other parts of the digestive tract, or 
cancer of the female genitals, and occasionally to cancers of 
some other part of the body. Less than 5 per cent, are primary. 
A fairly pathognomonic symptom-complex is enlargement and 
tumefaction of the organ, presence of a tumor which is painful 
on pressure, coHcky pains about the organ, radiating toward 
the right axilla, and the general cachexia with pronounced jaun- 
dice. In some cases nodules can be felt at the edge or upon the 
surface of the liver. The jaundice is of hepatogenous origin, 
noticeable on the conjunctiva and increasing as the growth 
interferes more and more with the secretion of bile. Owing to 
bile retention and interference with its passage to the gall- 
bladder and intestines, another set of symptoms is produced. 
These are, anorexia, especially a distaste for meat and fat; 
flatulence, meteorism, clayey, fotd-smelling stools, dark brown 
urine containing bile pigment, intense prtiritus, and, usually, 
nervous and cerebral symptoms. In some cases rapid emacia- 
tion with jaundice and a dull ache on pressure are the only 
suggestive symptoms. Primary cancer does not always give 
these symptoms. In cases in which the carcinoma is in the sub- 
stance of the liver and does not reach the surface, the organ will 
be increased in size but no nodiiles will be felt and icterus may 
be slight or even absent if the growth does not obstruct the free 
flow of bile. While there is no single pathognomonic sign, yet 
the history of a primary cancer, the rapid emaciation, jaundice, 
pain and increased size of the organ will siiffice to exclude most 
other diseases. Cirrhosis and syphilis are infrequent in the 
aged. It is sometimes difficult to differentiate between a cancer 
of the liver and that of an adjoining organ in the aged, as the 
liver then usually lies lower in the abdominal cavity than in 
maturity and growths in adjoining organs may become adherent 
to the liver. It is, however, only in the cases where the primary 
disease is so mild that it is overlooked that a mistake can be 
made. Cachexia is common to all types. Cachexia without 
marked jaundice points to cancer in some other organ than the 
liver, i.e., gall-bladder, or ducts, or pancreas. It is impossible 
to differentiate between cancer of the liver and that of the gall- 



28o PATHOLOGICAL OLD AGE 

bladder unless there is a palpable tumor which can be defined. 
In cancer of the pancreas the pain is to the left of the median line, 
there is often occlusion of the pylorus with dilatation of the stom- 
ach and if the tumor is palpable it will be found that it does not 
move with respiration. Glycosuria may also be present. 

There is no known cure for cancer of the liver and death 
generally occurs within a few months after its symptoms appear. 
If secondary to another cancer, operation can serve no purpose 
whatever. In the rare cases of primary cancer of the liver, 
benefit from an operation is possible although such operations 
are almost invariably fatal. All that can be done is to tempo- 
rarily relieve distressing symptoms by narcotics, analgesics, 
hypnotics, etc. 

Cancer of the Gall-badder. — With the exception of the 
location of the growth, the symptoms of cancer of the gall- 
bladder are the same as those of cancer of the liver. A palpable 
enlargement of the gall-bladder, because of its position under the 
liver, appears as an enlargement of or growth upon the liver 
itself. The disease is almost always secondary and what has 
been said of the prognosis and treatment of cancer of the liver 
applies to this condition. Gall-stones may give similar symp- 
toms but the history, paroxysmal colic, possible finding of 
stones in the stools on the one hand, and the history of a primary 
cancer or lymphatic involvement and rapidly progressive ca- 
chexia, will suffice to differentiate between them. 

Cancer of the gall-ducts cannot be differentiated from he- 
patic or biliary cancer. 

Cancer of the Pancreas. — Cancer of the pancreas is rare, 
but most cases occur in advanced age. The clinical picture 
described by Bard and Pic includes icterus, progressive and 
without remissions, enormous distention of the gall-bladder, 
readily perceived upon palpation, no increase in the size of the 
liver, temperature habitually subnormal, rapid emaciation and 
cachexia, short duration of the disease, sometimes a tumor in 
the epigastrium, absolute decoloration of the fecal matter, 
abundant biliary pigment in the urine and frequent albumi- 
nuria. In the absence of tumor there symptoms apply as well 
to cancer of the gall-bladder. DaCosta found a tumor in 13 
out of 137 cases of cancer of the pancreas. More frequent 
symptoms are pain in the region of the pancreas, the symptoms 



PROSTATIC CANCER 28 1 

of pyloric or duodenal stenosis, fatty stools and glycosuria. 
While the diagnosis of a cancer is not difficult in the presence 
of rapidly progressive cachexia and pain, in the absence of a 
tumor it is often impossible to determine whether the cancer 
is in the pancreas, duodenum or gall-duct. Cancer in the body 
or tail of the pancreas is very rare and when it occurs it does 
not produce jaundice, as the growth doer not compress the 
bile-duct. There is, however, pain, constant or paroxysmal, 
not aggravated by food, radiating to the left and of more inten- 
sity than in any other abdominal tumor. Packard points out an 
area of tenderness above and to the left of the umbilicus indica- 
tive of pancreatic disease and this with the cachexia and other 
symptoms of cancer is sufficiently suggestive to make a fairly 
certain diagnosis. The only treatment is surgical. Symp- 
tomatic remedies may be employed for the relief of pain and to 
supply medicinally the deficient pancreatic juice and bile. 

Prostatic Cancer. — Prostatic cancer is one of the more fre- 
quent forms of cancer in the aged. It is usually a primary 
scirrhus, occurring either as a cancer growth upon an enlarged 
prostate or as a hypertrophied prostate which became cancer- 
ous. Fuller says 1/7 or 1/8 of cases coming under his observa- 
tion with symptoms of prostatic obstruction were cancer. 
An early symptom of a primary cancer is an increased fre- 
quency of urination and rapid symptoms of obstruction which 
may appear in from four to six weeks, later, involvement of 
adjoining tissues and cachexia. In some cases there are no 
early symptoms except those of hypertrophy, which may exist 
for years before the obstruction is sufficiently marked to give 
decided symptoms and these symptoms proceed slowly. Hema- 
turia, the blood appearing at the end of urination, points to 
cancer or acute cystitis, but when associated with prostatic 
obstruction it is strongly suggestive of cancer of the prostate. 
Digital rectal examination reveals a hypertrophied prostate 
usually nodular, irregular, hard and when adjoining tissues are 
involved it is immovable or there is a sensation under the finger 
as if adjoining tissue is being dragged along. Pain, except the 
dull ache that accompanies hypertrophy, does not occur until 
adjacent tissues are involved and then it is frequently a sharp 
pain radiating from the groin down the thighs, and toward 
the sacrum, occasionally to the suprapubic region. When the 



282 PATHOLOGICAL OLD AGE 

active symptoms, frequent urination, rapidly increasing pros- 
tatic obstruction with hypertrophy, blood at the end of luin- 
ation, with rapid emaciation and other concomitants of cachexia 
appear, a mistake is hardly possible. The only successful treat- 
ment of prostatic cancer is early extirpation of the gland. If 
the disease has invaded adjoining tissues, there is no likelihood 
that any operation can radically free the patient of his trouble 
(Fuller). The increasing obstruction to urination will sooner or 
later make operative interference imperative. Drug treatment 
is useless except for the relief of pain, when the narcotics may be 
given. 

Cancer of the Bladder. — Cancer of the bladder occiu*s occa- 
sionally in the aged male and less frequently in the aged female. 
It originates usually in a benign papillary fibroma which may 
have existed for years. Secondary cancers generally follow 
uterine cancer in the female and cancer of the rectum or prostate 
in the male. There are no pathognomonic symptoms of cancer 
of the bladder unless particles of the growth are found in the 
urine. The usual symptoms, pain, hematuria and dysuria, 
may occur in other conditions, notably in benign tumors and 
in acute cystitis, while the symptoms of some cases of cancer 
are mild and intermittent. If above-mentioned symptoms 
appear in the course of a cancer of the rectum, prostate or uterus 
it is strongly suggestive of secondary cancer of the bladder. A 
positive diagnosis, however, requires the use of the cystoscope 
or the frequent examination of the urine for cancer cells. The 
tumor is rarely large enough or located so favorably that it can 
be felt. In primary cases cachexia appears late. 

If the disease is primary and localized surgical measures may 
effect a cure. If secondary cancers have occurred, operation is 
useless except possibly to relieve an occlusion of the sphincter. 
Bangs reports several cases of inoperable cancer in which daily 
irrigation of the bladder with a hot solution (100° raised slowly 
to 105° F.) of 1/2 per cent, creolin relieved the irritability, 
lessened the hemorrhage and diminished the size of the growth. 
The effect was not permanent but relief was secured for several 
months. 

Cancer of the Testicle. — Cancer of the testicle in the aged is 
almost always secondary to cancer of the prostate, bladder or 
rectum, and is then readily diagnosed by its rapid increase in 



CANCER OF THE FEMALE GENITALS 283 

size. It is not painful except on pressure. When occurring as 
a secondary cancer the neighboring lymphatics are already infil- 
trated and operation is useless. In the rare cases of primary 
cancer in the aged the disease may remain quiescent for years, 
providing the testes have been removed early. The danger of 
delay lies in the involvement of the ileolumbar lymphatics and 
extension through them. If these glands have not been affected 
complete cure is possible. 

Cancer of the Scrotum. — Cancer of the scrotum usually 
occurs as a papillomatous growth on the site of a scar, wart or 
eczema and follows the usual course of skin epithelioma. The 
treatment is excision. If performed before the lymphatics 
are involved complete cure is possible. 

Cancer of the Penis. — Cancer of the penis may occur as a 
primary or secondary disease. The usual location is upon the 
glans where it begins as a painless wart which rapidly increases, 
forming a cauliflower excrescence. It rarely invades the corpus 
cavernosa, but the inguinal and retroperitoneal glands are 
involved early. In those cancers which involve the skin, as 
in cancer of the penis and scrotum, early operation generally 
affects a cure, providing the neighboring glands are not in- 
volved, or if involved, are completely removed. Treatment 
with the X-ray, radium, etc., is still experimental and while 
justifiable they often fail and valuable time is lost thereby. 

Cancer of the Female Genitals. — In considering cancers in 
the aged we must include cancers of the female genital organs, 
although these belong exclusively in the domain of the gynecolo- 
gist. The most frequent of these is cancer of the uterus. This 
generally begins as a primary benign neoplasm which becomes 
malignant. A provisional diagnosis can usually be made if, 
after the menopause, a hemorrhage or a serosanguineous dis- 
charge occurs, or if a persistent watery leucorrhea becomes 
blood tinged or assumes a fetid odor. Neuralgic pains occur 
if a nerve is pressed upon ; usually, however, there is little pain, 
but a constant dull ache in the lumbar region. Violet says that 
an early diagnosis can usually be made by introducing a sound 
and gently moving it over the inner surface of the uterus. If 
there is cancer the physician can feel the sound scrape over the 
roughened surface of the growth. To make the diagnosis abso- 
lute, ciirettement and microscopic examination of the scrapings 



284 PATHOLOGICAL OLD AGE 

are necessary. Cachexia sets in early but is not well marked 
until the disease is well advanced. Montgomery points out 
that, where there is a history of previous tubal inflammation a 
menorrhagia and watery discharge indicates cancer of the Fallo- 
pian tube. Cervical cancer can usually be seen through a 
speculum and is easily felt. Moiilton says, however, that when a 
cervical cancer has reached the stage when it can be diagnosed 
unhesitatingly by the touch, eye, or history, then it has reached 
the border line between possibility and impossibility of cure. 
The early treatment is solely surgical, and delay occasioned by 
the use of medical measures simply lessens the chances of suc- 
cessful operation. Cancer of other parts of the female genitals 
is rare in the aged. When one occurs it is usually an epithelioma 
following a surface lesion such as eczema, excoriations from irri- 
tating discharges, scars of chancres or chancroids, etc. The 
treatment is excision of the mass but recurrence either on the 
site of the original growth or in the neighboring inguinal glands 
is of frequent occurrence. 

Cancer of the Breast. — This is usually a primary cancer, 
occurring in most cases soon after the menopause. According 
to Isaacs from 80 to 90 per cent, of all tumors of the breast are 
malignant and of the remainder a large proportion will become 
malignant if permitted to progress. The early symptoms are 
the presence of a hard mass, pain or tenderness and diminished 
mobility of the breast with elevation of the nipple of the affected 
side. A bloody discharge from the nipple is strongly suggestive 
of carcinoma. Later symptoms are retraction of the nipple, 
adhesion of the growth to the chest wall, lymphatic involve- 
ment, edema of the arm, ulceration, and cachexia. The treat- 
ment is surgical ; the earlier performed the better the prognosis. 
Abbe succeeded in healing an ulcerating inoperable cancer of 
the breast by radium. 

GRAWITZ'S CACHEXIA 

Etiology. — This disease, described by Grawitz as a ''fatal 
cachexia without discernible anatomical cause," somewhat 
resembles pernicious anemia, but the red blood cells show no 
degenerative change, though they may be diminished in number. 
No change in any organ or tissue has been found to explain the 
rapid anemia, emaciation, loss of strength and general physical 



CHRONIC LARYNGITIS 285 

breakdown, and it is assumed that the disease is due to some 
deleterious substance which has gained access to the blood; 
possibly the chromaffine substance of the adrenals. 

Symptoms. — The symptoms are rapidly increasing pallor, 
emaciation, loss of strength, and a mental and physical depres- 
sion, leading to fatal exhaustion. 

The differential diagnosis between this disease and perni- 
cious anemia rests upon the examination of the blood. The red 
cells number from 1,000,000 to 3,000,000 and they show no 
degenerative change. The disease resembles the cancer ca- 
chexia and can be distinguished from cancer only by the local 
and secondary symptoms of the latter disease. 

Treatment. — There is no known remedy. It is usually 
treated as pernicious anemia, and is always fatal. 

CHRONIC LARYNGITIS 

Chronic Laryngitis occurs either as a localized disease or a 
part of a more extensive chronic inflammation of the nares, 
pharynx, bronchi, etc. It appears in two forms, a hyper- 
trophic catarrh corresponding to chronic hypertrophic bron- 
chitis, and an atrophic catarrh corresponding to the senile 
atrophic bronchitis. 

Etiology. — The hypertrophic form of chronic laryngitis 
occurs most frequently in speakers, singers, and others who use 
the voice excessively, or in those who have had repeated attacks 
of acute laryngitis, or from extension of a chronic catarrh into 
adjoining tissues and lastly after infectious diseases in which 
the mucous membranes are profoundly involved, as in influenza 
and tuberculosis. The atrophic form occurs from the same 
causes that produce senile atrophic bronchitis. This form of 
laryngitis is a true senile disease, depending upon the presence 
of an atrophied mucous membrane which had been irritated. 

Symptoms. — In the hypertrophic form there is hoarseness, 
especially in the morning until the secretion which has collected 
during the night has been expelled. Involvement of adjacent 
tissues, as thickening or paresis of the vocal cords, may cause 
complete aphonia. There is a persistent feeling of tickling or 
irritation, rarely pain, a desire to cough but no relief after 
coughing, occasional dysphagia and dyspnea. In the atrophic 
form the voice is squeaky and weak but there is no hoarseness 



286 PATHOLOGICAL OLD AGE 

or aphonia, the throat feels dry but there are occasional spas- 
modic attacks of coughing with expectoration of a tenacious 
gray mucus. If the mucus accumulates upon the cords or 
controlling muscles there will be hoarseness, perhaps aphonia, 
but with the removal of the secretion the voice is again thin and 
squeaky. The diagnosis can readily be established by the 
laryngoscope. The grave forms of laryngitis associated with 
tuberculosis, cancer or syphilis can generally be differentiated 
by the history and accompanying symptoms of the primary 
disease. 

Treatment. — In the atrophic form of chronic laryngitis local 
stimulation is required and can best be accomplished by the 
inhalation of hot water to which menthol and eucalyptol have 
been added. If the expectoration is purulent, oil of turpentine 
inhalations should be used instead. If the mucus is thick and 
scanty the syrup of the hypophosphite of ammonium should be 
given in dram doses several times a day. In the hypertrophic 
form local application of mild astringents is indicated, such as 
blowing dry astringent powders or brushing the inflamed area 
with a weak solution of iodine or nitrate of silver. 
Hygienic measures and prophylaxis are self-evident. 

CHRONIC HYPERTROPHIC BRONCHIAL CATARRH 

This is the old man's winter cough, the most frequent 
bronchial affection of the aged, and bronchiectasis is almost al- 
ways associated with it. 

Etiology. — This form of bronchitis comes on with the advent 
of cold weather and is due to the alternate chilling and warming 
of the bronchial mucous membrane, from the difference in 
temperature between the inspired and expired air. It does not 
appear when the patient spends the winter in a warm equable 
climate. The disease occurs most frequently among those who 
have been exposed for years to such deleterious influences as 
dust, vapors, rapid temperature changes, etc., and, in almost 
every case, a tendency to catarrhal affections, carried over from 
earlier life, can be established. It is occasionally found in 
cases where excessive cautiousness against temperature changes 
and other causes of bronchitis has produced a condition of 
great sensitiveness in the bronchial mucous membrane. In 



ii 




Lung, Emphysema and Bronchiectasis. (Natural size.) 
(From Coplin's "Manual of Pathology.) A. Emphysema, 
vesicle. B. Enlarged peribronchial gland. C. Enlarged 
peribronchial gland, pigmented. D, D, D. Dilated bronchi. 



CHRONIC HYPERTROPHIC BRONCHIAL CATARRH 287 

such, a slight indiscretion as a draught, or a momentary chilling 
of the surface, produces a bronchitis. 

Pathology. — There is a passive hyperemia with thickening of 
the mucous membrane and enlargement of the mucous glands. 
The latter are usually open and are surrounded by dark-colored 
zones. The blood-vessels are filled and tortuous. Numerous 
small elevations and depressions are found in the mucous walls 
and the tissue feels soft and velvety. Later on, if there have 
been violent fits of coughing weak spots in the bronchial walls 
will result which dilate, producing bronchiectasis. These dilata- 
tions form sacs and pouches and may become cystic reservoirs 
of mucus or of muco-purulent matter. In some cases there are 
alternating areas of dilatation and stenosis, the latter caused by 
hypertrophy of the mucous membrane or by hyperplasia of 
5brous connective tissue. The mucous membrane of these 
dilatations is sometimes atrophied and leathery and under 
severe strain of coughing it may rupture permitting the contents 
to enter the lung tissue. 

Symptoms. — Chronic hypertrophic bronchial catarrh begins 
with a slight cough which gives little distress and is followed 
two or three days later by an abundant expectoration. The 
expectoration is muco-purulent, thick, yellow, sometimes tinged 
with green. A brownish expectoration, if specially abundant 
in the morning and associated with a spasmodic cough, indicates 
bronchiectasis. In some cases of chronic hypertrophic bron- 
chitis the expectoration becomes purulent, thin and grayish, 
or heavy and greenish, and has a fetid odor. This may come 
from abscess or gangrene of the lung, tuberculosis, or long 
retention in a bronchiectatic reservoir where the mucus became 
purulent. In the last case there are no severe constitutional 
symptoms, but if due to abscess or gangrene there are symptoms 
of septic infection. The physical signs are as in simple bron- 
chitis. Large dilatations gave amphoric breathing, cavernous 
resonance, possibly pectoriloquy and large bubbling rales. The 
physical signs of bronchiectasis are not clear but the diagnosis 
can usually be made by the large amount of secretion brought 
up in the morning with a spasmodic cough while, if there is no 
compHcating bronchiectasis, the amount brought up in the 
morning exceeds but by little the amount expectorated at other 
times of the day. The symptoms of bronchiectasis persist 



288 PATHOLOGICAL OLD AGE " 

during the whole year while the symptoms of hypertrophic 
bronchitis disappear with the advent of warm weather to reap- 
pear at the next approach of winter. 

Treatment. — The successful treatment of chronic hyper- 
trophic bronchial catarrh depends upon the ability of the pa- 
tient to go to a warm equable dry climate, but not at a high 
elevation, and remain there all winter. The disease will prob- 
ably not appear while he is there but if he returns to a cold 
climate, the disease will return also. As long as he is obliged 
to breathe cold air he will suffer, and medicinal treatment is 
only palliative as long as the causative factor remains. Little 
can be done by internal medication, but the inhalation of creo- 
sote, terebene or eucalyptol is sometimes of service. Expec- 
torants useful in acute bronchitis are generally contraindicated 
in this disease. The occasional administration of i/ioo grain 
of atropine may diminish the secretion and if the secretion is 
tenaceous the muriate of ammonia with syrup of senega may 
be given. If there is a putrid bronchitis a 2 per cent, spray or 
inhalation of phenol may be used to destroy the fetor but the 
treatment must be directed to the causative condition. Hy- 
gienic measures, such as warm clothing, freedom from draughts, 
feet protected from dampness, etc., are necessary adjimcts to 
the treatment. 



PULMONARY EDEMA 

Pulmonary edema occurs frequently in the aged as a sec- 
ondary terminal disease, appearing in some cases during the 
death struggle. More often it initiates the series of phenomena 
that are associated with the process of dissolution. There is a 
transudation of serum from the blood-vessels into the intersti- 
tial tissue and air vesicles, blocking the latter and preventing 
aeration of blood. A recurrent type has been described but 
in the aged the first attack is almost always fatal. 

Etiology. — In most cases, in the aged, it follows a passive 
hyperemia, either a hypostatic congestion due to long confine- 
ment to one position, or an obstruction to the return circulation 
due to cardiac or pericardial disease. In these cases separation 
of the serum occurs during stasis and it passes out of the vessels. 
Pulmonary edema also occurs in hydremic conditions as in 



PULMONARY EDEMA 289 

nephritis, cirrhosis of the hver, anemia, scurvy, etc., in which 
diseases there is a tendency of the serum to ooze out through 
the vessels. In some inflammatory conditions, as in pneumonia, 
bronchiolitis, etc., there may be stasis with separation of the 
serum from^ the blood. In extreme debility with weakened 
circulation, and in man}^ fatal diseases, there is, toward the end, 
a relaxation of the blood-vessels w^hich permits the exudation 
of serum and its transudation into the surrounding tissues and 
into the air vesicles. 

Pathology. — The affected portion of the lung becomes 
lighter in color and heavier in weight, it pits upon pressure and 
upon opening the chest the lung does not collapse. Serum is 
found in the alveoli and interstitial tissue and if there has been 
a pulmonary congestion the serum is blood streaked. On 
sectioning, the serum exudes. 

Symptoms. — The first symptom of pulmonary edema is 
usually a sudden, severe, or a rapidly increasing, dyspnea which 
is soon followed by an abundant, frothy mucus which may be 
blood streaked. The respiration is increased in frequency and 
the patient makes violent efforts to get air, sitting up and bring- 
ing into play all the respiratory muscles. There is inspiratory 
and expiratory dyspnea, the expiration being accompanied by 
an audible rattle as the air bubbles up through the tubes that 
are occluded by serum. C^'anosis often occurs toward the end. 
Some cases die of asphyxiation with the symptoms of choking, 
in others there is coma. The physical signs are dulness over the 
site of the edema, bubbling rales heard with inspiration and at 
the beginning of expiration, feeble respiratory murmur. The 
sudden or rapid onset and the history of an antecedent causa- 
tive disease distinguish it from other pulmonary diseases. 

Prognosis. — Pulmonary edema in the aged is almost invari- 
ably fatal, death usually occurring in from one to twenty-four 
hours after the onset of the disease. It occasionally makes its 
appearance during the last few minutes before death. 

Treatment. — In a disease w^hich is almost alw^ays rapidly fatal 
we are justified in employing any measures which might pro- 
long life. The usual remedies, wet or dry cups, hot fomenta- 
tions, mustard and turpentine applications, are useless in the 
aged. The time for their use was diuing the passive hyperemia 
when they might have equalized the circulation by producing 
19 



290 PATHOLOGICAL OLD AGE 

a superficial hyperemia, but after transudation of serum has 
taken place they cannot stimulate absorption. In hydremic 
states the theoretical treatment is to secure rapid elimination of 
fluid by means of hydragogue cathartics, diuretics and dia- 
phoretics. Such rapid elimination, however active, weakens 
the heart and does not remove the serum from the air vesicles. 
Venesection will either immediately destroy the patient or will 
afford but temporary relief by relieving the local congestion. In 
such cases there may be a temporary absorption of the transu- 
date, but the vessels soon fill again and the serum will again 
transude into the vesicles. The report that a case was re- 
lieved by turning the patient on his stomach, placing him across 
the bed and supporting his abdomen with a high bolster, while 
his head was hanging over the edge, thereby allowing the serum 
to flow out by gravity, induced the author to try this in one case. 
The patient suffocated. Oxygen inhalation will relieve the 
cyanosis for a time, but as the disease progresses and greater 
areas of lung tissue are involved, the blood becomes more con- 
taminated, finally the oxygen cannot aerate the blood suffi- 
ciently and coma and death ensue. 

Suprarenal preparations will sometimes control and pre- 
vent further transudation if given at the onset of the disease, 
but they do not produce reab sorption of the transudate present 
in the air vesicles. If there is but a small quantity, it may be 
expectorated and the patient tided over by oxygen inhalations. 
The adrenal preparations are powerful vasoconstrictors and if 
there is cerebral arteriosclerosis they may produce cerebral 
apoplexy, but the gravity of pulmonary edema in the aged 
overbalances the possibility of producing apoplexy. The rapidly 
acting eliminants are powerful cardiac depressants and, if 
given, they must be combined with rapidly acting cardiac 
stimulants, preferably strychnine and digitalin. This applies 
especially to the drastic hydragogue cathartics. 

PULMONARY GANGRENE 

Etiology. — Gangrenous destruction of lung tissue results 
from the action of putrefactive bacteria upon diseased tissue. 
It is always a secondary disease, most frequently following an 
aspiration or deglutition pneumonia, or other form of pneumonia, 



PULMONARY GANGRENE 29 1 

fetid bronchitis or bronchiectasis, cancer or tuberculosis. It 
may, however, occur in any pulmonary affection or may originate 
from extraneous sources of infection such as a perforating 
esophageal cancer or empyema, degenerating bronchial glands or 
traumas. A non-putrid gangrene occasionally occurs in the 
course of diabetes. A pulmonary embolus is also frequently 
followed by gangrene. 

Pathology. — Pulmonary gangrene may be acute or chronic, 
circumscribed or diffuse, single or multiple. The tissue becomes 
first jelly-like, then softens into a pultaceous gray or greenish 
mass of fetid matter that contains shreds of tissue which had not 
undergone complete destruction. In the diffuse form this mass 
extends into adjoining healthy tissue, while in the circumscribed 
form the mass is limited by a growth of connective tissue. 
Where an opening into a bronchial tube exists, the mass is ex- 
pectorated and the cavity may become completely cleared. An 
opening into the pleural cavity may cause a pyopneumothorax. 
There is usually an acute or a fetid bronchitis and often a pleurisy 
or empyema associated with pulmonary gangrene. 

Symptoms. — This disease in the aged is usually acute and 
begins with active symptoms of septic infection, such as irregular 
fever, perspiration, and prostration. The severity of the symp- 
toms depends upon the extent of the gangrene. If it is a small, 
single, localized area, symptoms will be mild, while in an ex- 
tensive diffused gangrene there will be high fever, rapid prostra- 
tion and emaciation, finally cerebral symptoms of delirium and 
coma appear and death soon results. An early, and sometimes 
the first, symptom of pulmonary gangrene is cough with fetid 
expectoration. The sputum is thin, greenish or dark gray or 
brown and contains, beside mucus and pus, bits of gangrenous 
tissue, Dittrich's plugs, crystals of fatty acids and under the 
microscope it is seen to be loaded with bacteria. The odor of 
the sputum is the decomposition odor of nitrogenous matter 
similar to the odor of decaying meat. This will often suffice to 
distinguish gangrene from abscess of the lung and bronchiectasis, 
in which the odor is due to fatty acids and resembles old cheese. 
There are sometimes traces of blood, and if a blood-vessel be- 
comes necrotic there \^^11 be a hemorrhage. 

Pulmonary gangrene in the aged is almost invariably fatal. 
Even in mild cases where the disease is localized and involves 



292 PATHOLOGICAL OLD AGE 

only a small area, as when a small foreign body has been as- 
pirated, there is always the danger of diffusion or the formation 
of secondary foci through aspiration of particles of putrid matter 
from the bronchi. Metastatic abscesses and gangrene may 
occur. 

Treatment. — Only in rare instances will medical measures 
avail, while operative procedure is likewise rarely successful. 
The medical measures are the inhalation of disinfectants, such 
as creosote, guaiacol, turpentine, etc., and the internal admin- 
istration of powerful expectorants as the syrup of the hypo- 
phosphite of ammonium (contraindicated in tuberculosis), 
syrup of senega or ipecac and also creosote, guaiacol and similar 
drugs. 

The strength must be maintained by tonics, concentrated 
foods, and small quantities of alcohol, while incidental symptoms, 
as fever, pain, insomnia, etc., must receive appropriate treat- 
ment. It is possible that serum therapy holds a cure for this 
disease but at present the only chance for recovery, slight though 
it be, lies in operation. 

Pyopneumothorax. — Pneumothorax, hydropneumothorax and 
pyopneumothorax are rare complications of pulmonary gangrene 
and occur when a gangrene or abscess opens into the pleural 
cavity. These diseases may occur from any cause which pro- 
duces an opening into the cavity from without, or from the lungs, 
pleural or abdominal cavity. They are, therefore, liable to occur 
as a result of surgical operations, empyema, tuberculosis, abscess, 
or gangrene of the lung, sudden inspiratory effort causing rup- 
ture of alveoli into the cavity and abscesses of the abdom- 
inal cavity opening through the diaphragm into the pleural 
cavity, etc. Pneumothorax and hydropneumothorax are ex- 
tremely rare, and when they occur they soon become infected. 
The symptoms which usually set in suddenly are pain and a 
sensation of tearing in the lung, dyspnea, sometimes cyanosis 
and anxiety, and occasionally expectoration of pus. The phys- 
ical signs are the same as in maturity, the auscultatory signs 
being especially well marked in later life. The distention of the 
affected side is not marked owing to the rigidity of the chest walls, 
but intercostal distention is obliterated. 

A cavity of a pulmonary tuberculosis may give similar 
physical signs but not the same symptoms, and is very rare in old 



PULMONARY ABSCESS 293 

age. Treatment is usually fruitless, as the causative condition is 
generally of a fatal nature. Aspiration may give temporary 
relief. 



PULMONARY ABSCESS 

Etiology. — Abscess of the lung occurs occasionally in old 
people, most frequently as a secondary complication of pneu- 
monia. In influenza the bacilli sometimes cause minute ab- 
scesses in the lung, and the aspiration of purulent matter from 
the nose, throat or bronchi or of particles of food may also occa- 
sion it. Less frequent causes are perforation of the lung from 
an empyema, bronchiectasis or other pus cavity, or from without 
as from bullet wounds and other trauma, pyemia with the 
formation of metastatic abscesses, and tuberculosis. 

Symptoms. — The symptoms in the aged are generally vague, 
although there are numerous symptoms and signs pointing to 
pulmonary disease and sometimes to septic infection. Where 
the disease follows or complicates an infectious disease, the 
earliest symptom is a purulent expectoration. The pus in the 
sputum is mixed with mucus and does not form coin-shaped 
plaques as in purulent bronchitis, nor lumps as in tuberculosis. 
The pus cavities in the senile are often little more than distended 
slits in the tissues, seldom rounded cavities such as appear in 
tuberculosis. The slit-like cavities are usually found in the 
lower lobe, the round cavities in the upper lobe where they 
simulate tuberculosis and in most cases a bacteriological exami- 
nation is then necessary to determine whether it is a tubercular 
abscess or not. The physical signs of pulmonary abscess in 
the upper lobe are the same as in tuberculosis. The tympanic 
percussion note, prolonged expiration, large and fine moist 
rales and cough with expectoration which persists day and night, 
all point to a cavity which is constantly being emptied. When 
the abscess is in the lower lobe the pus collects during night and 
necessitates prolonged coughing and expectoration in the morn- 
ing, mth but little cough or expectoration during the rest of the 
day. 

When the abscess is due to an aspiration or deglutition 
pneumonia there is little or no elevation of temperature but 
cachexia with anemia and emaciation soon sets in. The sputum 



294 PATHOLOGICAL OLD AGE 

becomes purulent and shows on standing the characteristic 
layers of purulent expectoration. The heavy grayish lower layer 
contains bacteria, leucocytes, fatty acids, and elastic fibers. This 
layer has a foul, and in an old abscess, a fetid necrotic odor. 
The middle layer is grayish and watery and if a blood-vessel 
has been involved the liquid will be colored red or brown. The 
upper layer is mucus and contains air cells. The sputum of 
bronchiectasis is similar, . and a deep-seated bronchiectasis in 
the lower lobe often gives signs similar to the physical signs of 
abscess. In these cases the more rapid development and the 
cachexia point to abscess, but the history may be necessary to 
determine the diagnosis. 

Treatment. — The only certain method of emptying a pus 
cavity in the lung is by operative procedure, aspiration, or by 
resection of ribs and then aspiration. The uncertainty of the 
exact situation of the abscess makes rib resection the better 
coiirse, but the method must be left to the surgeon. If the 
local and constitutional symptoms are mild, medicinal measiu-es 
can be employed to favor emptying of the pus cavity by expec- 
toration. This can sometimes be accomplished through the 
inhalation of guaiacol or creosote, the internal administration 
of expectorants as muriate of ammonia, syrup of senega and 
ipecac, and a postin-e which will permit the free flow of the 
sputum toward the mouth. This can be produced by raising 
the foot of the bed. The use of hygienic regulations, fresh air, 
concentrated food, tonics, etc., is self-evident. 

CARDIAC HYPERTROPHY 

Simple hypertrophy is normal in the aged, the increasing 
hyperplasia keeping pace with the increase in the resistance of 
the vessels, caused by arteriosclerosis. In the physiological 
hypertrophy the left ventricle alone is involved but there is no 
increase in the size of the cavity. When the walls of any of the 
other cavities become hypertrophied or dilatation sets in we 
have a pathological condition to deal with. 

Etiology. — Cardiac hypertrophy is the result of excessive 
work, the muscle tissue increasing as all striped muscles increase 
in volume, when actively employed. 

The principal causes for left ventricular hypertrophy are 



CARDIAC HYPERTROPHY 295 

increased arterial resistance as in arteriosclerosis, nephritis, 
or as a result of vasoconstrictor drugs; or toxic irritation as in 
uremia, goiter, gout, and infectious diseases; cardiac defects as 
valvular disease or myocarditis, or pericardial adhesions; finally 
excessive or prolonged exercise as in athletic sports. 

Right ventricular hypertrophy occurs when there is some 
obstruction to the circulation in the lungs, as in emph^^sema, or 
when there is mitral disease present. Pericardial adhesions 
may cause excessive work for the ventricular muscle and produce 
hypertrophy. 

Auricular hypertrophy is invariably accompanied by dilata- 
tion and is due to valvular disease. 

Pathology. — The heart is increased in size, it is rounder 
and less pointed than in its normal state. If the hypertrophy 
is confined to the left ventricle, the heart is pear shaped, but 
if both ventricles are involved it is longer and oval. The walls 
may be increased to twice their normal size, the increase being 
hyperplastic (numerical hypertrophy). 

Symptoms. — In the simple hypertrophy of old age associated 
wdth arteriosclerosis there are no symptoms referable to the 
heart as long as the heart's action is not disturbed. Exercise 
or excitement will produce palpitation and may produce cerebral 
hyperemia mth headache, vertigo and tinnitus. At such times 
the face becomes flushed, there may be a nervous twitching and 
psychic manifestations, such as irritability of temper, may appear. 
Similar symptoms are produced when there is cardiac irritation 
from a distended stomach. In the hypertrophy associated with 
other cardiac lesions the symptoms of the latter mask the symp- 
toms of the hypertrophy. 

The physical signs in left ventricular hypertrophy are an 
increased area of impulse and visible cardiac pulsation, an in- 
creased area of the apex beat to the left of and below its normal 
position, percussion dulness is increased to the left and downward, 
and the heart sounds are increased in intensity, the first sound 
being dull and prolonged. 

In right ventricular hypertrophy there is epigastric pulsation, 
the apex beat is displaced to the right and dow^nward, percussion 
dulness is increased to the right of the sternum, and the second 
sound is heard loudest over the pulmonic orifice. In auricular 
hypertrophy and dilatation the percussion area is increased up- 



296 PATHOLOGICAL OLD AGE 

ward. Except in simple hypertrophy of the left ventricle the 
symptoms and signs are modified by the accompanying lesions 
and if there is dilatation present, all of these may be altered 
except the area of percussion dulness. Hypertrophy is differ- 
entiated from dilatation by the regularity and strength of the 
heart action, by the more intense second sound, absence of mur- 
murs and absence of symptoms referable to pulmonary engorge- 
ment. 

With increasing arterial resistance there is an increasing 
hypertrophy to a point where the limit of functional capacity 
is reached. Beyond this point compensation is broken, dilata- 
tion ensues and the further progress is the history of cardiac 
dilatation. 

Treatment. — The main indication in the treatment of simple 
hypertrophy is to maintain compensation and to defer as long as 
possible the inevitable break w^hen the limit of the functional 
capacity is reached. If there is an underlying pathological 
condition this must receive attention. Hygienic measures 
must be taken to prevent intense or prolonged mental and 
physical strain, excesses or fatigue. Heart stimulants are con- 
traindicated and only in case of palpitation following excessive 
exercise or in case of fever are cardiac sedatives like aconite or 
veratrum permissible. Alcohol must be strictly forbidden. 

CARDIAC DILATATION 

Cardiac dilatation is an increase in the size of the cavities. 
It is invariably a secondary condition either following a hyper- 
trophy which has reached the limit of its functional capacity or 
some other condition which has impaired the tonicity of the 
heart muscle. There is a limit to the working capacity of muscle 
fibers, but prolonged or excessive work produces fatigue before 
this limit is reached. Further activity can be aroused only 
under a forced stimulus, until exhaustion sets in with complete 
inability to work under any stimulus. Fatigue demands rest 
and exhaustion compels rest, during which recuperation and 
repair take place. Ever}^ contraction of the heart is followed by 
a short refractory period during which it cannot respond to stim- 
ulation. This corresponds to the rest period following exhaus- 
tion. With the increasing arterial resistance, due to arterio- 



CARDIAC DILATATION 297 

sclerosis, the work of the heart is increased and this is made pos- 
sible by an increase in the number of muscle fibers or hyperplasia 
of tissue. Gradually the work increases more rapidly than the 
increase in tissue can keep pace with, while the rest period is not 
prolonged proportionately and the muscle finally reaches the 
point of the limit of its functional capacity. Then, being un- 
able to respond to further increased activity, the fibers begin to 
degenerate, lose their tonicity, stretch and cannot contract fully. 
Thus is then produced a distention of the walls with dilatation 
of the chambers. In some cases this is brought about by the 
weakening of the walls through malnutrition. In other cases 
the internal tension is greatly increased and the tonicity of the 
muscle fibers is thus impaired. This may occur during prolonged 
strain and it may occiu* rapidly or even suddenly upon any vio- 
lent and sudden exertion. In most cases, however, the in- 
ception of the dilatation arises from increased internal tension 
as soon as the limit of the functional activity of the heart muscle 
is reached. 

Etiology. — There are three general causes for cardiac dilata- 
tion: (i) exceeding the limit of the functional capacity of the 
heart, (2) degeneration of the heart and (3) increased internal 
pressure. The first is the usual cause in senile cases, and the 
method of production has been explained. The second, i.e., 
degeneration of the heart, may be due to the process of involu- 
tion, to toxins, especially that of pneumonia, to typhoid fever, 
influenza, erysipelas and other diseases accompanied by pyrexia, 
or to malnutrition. In these cases there is usually no change in 
the thickness of the walls. The third, or increased internal 
pressure, may occur secondarily to cardiac weakness with im- 
paired circulation, the auricles becoming overdistended while the 
ventricles are unable to completely empty themselves. This 
may occur in myocardial degeneration, valvular disease or 
arteriosclerosis. Increased internal pressure may also be pro- 
duced by the ingestion of large quantities of fluids. The so- 
called ''Miinchner Bier Herz" is a cardiac dilatation due to this 
cause. Sudden or prolonged exertion as in violent athletic 
sports may produce a rapid dilatation from increased internal 
pressure. This is the usual cause of death of contestants just 
after a supreme effort on the athletic field. In these cases the 
walls of the heart are generally thin. 



298 PATHOLOGICAL OLD AGE 

Pathology. — The cardiac walls may be normal, hypertrophied 
or thin. In senile cases there is usually hypertrophy and all 
chambers are dilated. In other cases the right ventricle is 
first dilated followed by the left auricle, right auricle and lastly 
the left ventricle. There is, however, no uniformity in the order 
in which the chambers become dilated and in some cases of myo- 
cardial degeneration the dilatation is localized over the seat of 
the degeneration. The muscle fibers show degenerative changes 
and frequently the nerve ganglia are altered. The venae cavae 
are generally dilated if the right auricle is dilated. Dilatation 
is generally associated with valvular disease and the valves show 
the well-known changes in structure and anatomical relations. 

Symptoms. — The symptoms vary with the form of dilatation. 
If there is a cardiac hypertrophy there may be a progressive di- 
latation without any symptoms, or with symptoms masked or 
counterbalancedby the symptoms of hypertrophy until dilatation 
becomes more marked or until a sudden strain produces a sudden 
or rapidly increasing dilatation. When occurring suddenly or 
rapidly there is a severe pain in the cardiac region, dyspnea and 
weak, rapid or irregular heart action. If coming on slowly there 
is but a gradual weakening of heart action and but occasional 
shortness of breath. These symptoms may be present for 
months before they are sufficiently severe to attract the atten- 
tion of the patient. In cases not accompanied by hypertrophy, 
the symptoms appear more rapidly and are more pronounced 
from the beginning. In the form especially in which the walls 
are thinner than normal, the early symptoms are quite marked. 
In these cases there is palpitation, arrhythmia, in which the rate 
is irregular and the force diminished, the pulmonary circulation 
becomes impeded and there is incomplete aeration of blood and 
dyspnea on slight exertion, the arteries are incompletely filled 
and the veins are distended. As the dilatation increases there is 
a constant palpitation or a feeling of throbbing and irregular 
wobbHng of the heart, the dyspnea becomes permanent, the 
face is pale, the lips cyanotic and on excitement the entire face 
becomes livid or cyanotic. The pulse is irregular and weak. 
Irritabihty results, followed later by diminished mental power. 
When the disease is far advanced, the symptoms become more 
marked, there is cyanosis, scanty albuminous urine, edema, 
occasional syncope, later the liver, spleen, kidneys and stomach 



CARDIAC DILATATION 299 

become involved through defective circulation and impaired 
venous return and their functions are disturbed. Dropsy may 
increase until there is general anasarca, but in the aged, death 
usually occurs from pulmonary edema before the dropsy is far 
advanced. 

The principal physical signs are the increased area of dulness 
with short, feeble heart sounds. There is often arrhythmia, 
either the galloping arrhythmia or embryocardia. There is an 
indistinct and increased area of cardiac impulse with a diffused 
and weak apex beat. In thin persons a wavy movement over 
the precardial space can be seen and felt. Occasionally a thrill 
can be felt and if the right heart is affected the jugulars are prom- 
inent and dilated. As dilatation is usually associated with val- 
vular disease there are also the symptoms and signs of the re- 
spective valvular lesion. In senile cases the pulse is of no service 
in determining the diagnosis. It is usually weak, irregular and 
intermittent but when the radial artery is sclerosed it may be 
hard, while beats may be lost in transmission from the heart to 
the wrist. 

Diagnosis. — Observation of the physical signs ought to 
differentiate dilatation from hypertrophy in w^hich the impulse, 
apex beat and heart sounds are strong and clearly defined. 
In thoracic aneurysm and mediastinal tumors the area of dul- 
ness is upward. In pericarditis -^i^ith effusion the area of dulness, 
friction soimds, regular rhythm, and absence of vesicular mur- 
mur in the parts of the limg covered by the effusion \\ill clear up 
the diagnosis. 

Prognosis. — The prognosis in senile cases is bad. The dis- 
ease is incurable and sometimes rapidly fatal. If it follows an 
aortic insufficiency or stenosis it usually runs a regular course; 
i.e., relative mitral insufficiency, dilatation of the left auricle, 
pulmonary engorgement, hypertrophy and dilatation of the 
right ventricle, then of the right auricle, with general venous en- 
gorgement. This is the order of cardiac involvement but it may 
proceed rapidly or slowly or one or more stages may pro- 
ceed more rapidly than others. Dilatation following diffuse 
myocardial degeneration proceeds rapidly and there is no order 
in the valvular involvement. Sometimes pulmonary engorge- 
ment evidenced by dyspnea and cyanosis occur soon after the 
initial symptoms of degeneration appear. Life can usually be 



30O PATHOLOGICAL OLD AGE 

prolonged with care and treatment, but death will result from 
cardiac exhaustion, pulmonary edema or from degeneration of 
some other organ. Treatment is the same as that of valvular 
lesions. 

FATTY DEGENERATION OF THE HEART 

Fatty degeneration when occurring in the aged is generally 
due to impaired nutrition through sclerosis, embolism or throm- 
bosis of the coronaries. It may follow fatty infiltration or 
occur in the progress of cancer. It is not, however, a true 
senile degeneration. It is assumed that where fatty infiltration 
exists, fat makes its way into the muscle cells. , In other cases 
protoplasmic activity is impaired and instead of reproducing 
protoplasm it produces a suboxidation product, fat. According 
to this view fatty degeneration is secondary to a primary 
degeneration due to impaired nutrition. 

Etiology. — Fatty degeneration may occur at any period of 
life and the same causes to which it may be due in earlier life may 
produce it in old age. The predisposing causes are, insufficient 
nutrition as from coronary sclerosis or from the general mal- 
nutrition of old age, from perverted nutrition as in general 
obesity and from fatty infiltration. These may also be the 
exciting causes. It may also occur in the course of infectious 
diseases, cachexias, Bright' s disease, chronic alcoholism, phos- 
phorus and arsenic poisoning, pericarditis, cardiac hyper- 
trophy, etc. 

Pathology. — If the degeneration is general, the heart may be 
enlarged, pale or yellowish and flabby, resembling fatty infiltra- 
tion, or it may show little or no change. In many cases the 
degeneration is localized, involving the walls of a single chamber 
or of a still smaller area. 

The muscle fibers lose their nuclei and striations, become 
granular and the sarcolemma is filled with granules. When 
the disease is far advanced the whole muscle cell seems to be 
filled with fat granules and oil globules. The disease rarely 
proceeds to that degree in the aged, as the whole heart is usually 
involved in these cases and owing to the general senile impair- 
ment of the organ, dilatation and its consequences follow early. 

Symptoms. — There are no early symptoms indicating fatty 
degeneration and there may be no change in the function of 




Fatty degeneration of heart, with thickened aortic 
leaflets and mitral stenosis (wooden wedge in button- 
hole opening), about one-half size. (Satterthwaite, 
Medical Record, May 14, 1910. 




/ ' ! 

Fatty degeneration of cardiac muscle, a beginning changes; b, com- 
plete deegeneration, X 250. Satterthwaite, Medical Record, May 
14, 1910. 




Abnormal deposition of fat, X845. (Satterthwaite. 
Medical Record, May 14, 1910,) 



FATTY INFILTRATION OF THE HEART 3OI 

the heart until dilatation sets in. As the disease progresses 
there are usually symptoms of defective heart power, rapid 
exhaustion and palpitation or arrhythmia upon exercise, 
dyspnea, giddiness, vertigo and syncope due to cerebral anemia, 
feeble pulse and apex beat, and upon auscultation the heart 
sounds are found to be feeble and the first sound almost inaudi- 
ble. The respiration is generally feeble and sighing with 
occasional attacks of cardiac asthma and in extreme cases the 
Cheyne-Stokes type of respiration may appear. Irritability of 
temper, probably due to cerebral anemia — a prominent symp- 
tom in all cardiac affections producing cardiac weakness — ^is an 
early symptom of fatty degeneration. An increased area of 
percussion dulness before 'dilatation may be due to hypertrophy 
or fatty infiltration. 

After dilatation has set in the symptoms are referable to 
that condition. Death m_ay result from sudden strain or 
emotion. 

Treatment. — The treatment of fatty degeneration is symp- 
tomatic and hygienic before dilatation takes place, the object 
being to prevent failing compensation. Mental and physical 
exertion must be avoided, especially sudden strains and emotions. 
High altitudes are injurious. Alcohol and tobacco are inter- 
dicted, liquids should not be taken with foods and the food 
should be easily digestible for prompt assimilation. Constipa- 
tion should be guarded against. Mild exercise is permitted 
but the patient must constantly bear in mind that a sudden strain 
may cause death. The Oertel terrain treatment and the 
Schott and Nauheim treatments are dangerous in old age. 
Digitalis is contraindicated, but in an emergency, when lost 
compensation has brought about a critical condition with irregu- 
lar, rapid, weak heart and dyspnea, and there is danger of cardiac 
exhaustion, and strychnia, carbonate of ammonia, aromatic 
spirits of ammonia and other cardiac stimulants have failed, 
we are justified in giving hypodermically digitalin combined 
with nitroglycerin in doses of i/ioo grain each. 

FATTY INFILTRATION OF THE HEART 

Fatty infiltration is not a degeneration nor a senile disease, 
although it occurs m.ost frequently in obese persons after middle 
age. 



302 PATHOLOGICAL OLD AGE 

Etiology. — In most cases it is part of the general process of 
suboxidation which causes obesity and is due to the same 
metabolic disturbance. It occurs mostly in women past the 
menopause and in men after the critical period which occurs 
about the fiftieth year. The underlying cause of obesity which 
frequently appears about this time is unknown. 

Pathology. — Fat deposits around the heart, between the 
auricles, in the auriculo-ventricular groove, about the right 
ventricle and between the bundles of muscle. The heart 
appears larger and is pale or yellow and flabby. In advanced 
cases there is usually fatty degeneration and dilatation. 

Symptoms. — There are no early signs or symptoms. It may 
be suspected when with increasing obesity there is dyspnea 
upon exertion and percussion reveals an increasing area of dul- 
ness. With the increase of fat about and in the heart, the heart 
muscle finds it more difficult to do its work, the heart becomes 
weakened and dilatation ensues. If fatty degeneration sets 
in, the dilatation proceeds more rapidly and the symptoms 
of that disease prevail. 

Treatment. — The treatment of fatty infiltration is the treat- 
ment of general obesity. When degeneration or dilatation sets 
in, the treatment must be directed to the new condition. 

VALVULAR LESIONS 

Valvular defect of some kind is found in most senile hearts, 
but they give no subjective symptoms as long as a compensatory 
hypertrophy exists. When compensation is broken and dilata- 
tion sets in, the symptoms become marked and the secondary 
diseases due to impaired circulation and venous engorgement 
quickly follow. The most frequent defects are aortic insuf- 
ficiency, aortic stenosis and mitral insufficiency. Uncompli- 
cated mitral stenosis is rare as the principal causative factor, 
acute endocarditis following rheumatism, infectious disease or 
toxin rarely occurs in old age. 

The underlying cause of stenosis in old age is atheroma, either 
originating in the valve itself or extending to the valve from senile 
endocarditis or aortic atheroma. Insufficiency may be due to 
atheroma, cardiac dilatation or myocardial disease. There are, 
however, cases of aortic insufficiency in which the valve itself 



Tracing of Pulse in ]\IitraI Stenosis. (From Tyson and Fussell's 
''Practice of Medicine.") 




Pulse-tracing of Aortic Stenosis. (From Tyson and Fussell's 
"Practice of Medicine.") 




Tracing of Pulse of ]Mitral Insufficiency. (From Tyson and 
Fussell's "Practice of Medicine.") 





Tracings of Pulse of Aortic Regurgitation. (From Tyson and 
Fussell's Practice of Medicine.") 




Sphygmogram of an Atheromatous Vessel — The Pulsus 
Tardus. (From Tyson's "Practice of Medicine.") 



\ 



VALVULAR LESIONS 303 

is not diseased but in which, owing to a dilatation of the aorta, the 
aortic ring is overstretched and cannot close completely. 
Preble has reported a similar relative insufficiency of the pul- 
monary valves. As a result of atheroma and degenerative 
changes in its structure, a valve may be both thickened and con- 
tracted producing insufficiency and stenosis at the same time. 
In some cases the mitral and aortic valves are involved, the 
mitral involvement being usually secondary to the aortic disease. 

As long as the hypertrophied heart can compensate for the 
impairment of the circulation caused by diseased valves and 
sclerosed vessels, there may be little or no disturbance in the 
circulation and no marked symptoms of valvular disease, though 
the physical signs may be pronounced. When decompensation 
sets in, the symptoms of cardiac dilatation prevail, modified or 
accentuated by the symptoms of the valvular lesion. Patients 
having valvular disease in early life rarely reach old age and the 
valvular diseases found in the aged usually originate at that 
period of life. 

The diagnosis of valvular disease in the aged is not difficult 
if there is but a single valvular defect. If there are two or more 
defects a discerning ear may be able to distinguish the separate 
murmurs, but other physical signs and the symptoms may be too 
complicated to be interpret able. A disturbing factor in these 
cases is the atheromatous aorta which adds its own train of 
symptoms. Where there is arrhythmia with a variable cardiac 
impulse the carotid pulsation will serve to determine the systolic 
sound. A frequent source of error in diagnosing valvular lesions 
is the altered position of the heart. In the aged the second sound 
is heard loudest in the third intercostal space and if the heart is 
greatly atrophied it may be most intense in the fourth intercostal 
space. 

If degenerative changes originate in the valves, they begin by 
a thickening of the edge which becomes opaque, firm and in- 
elastic. In the aortic valve the degenerative change begins in 
the corpus Arantii, and in the mitral valve at the margin of the 
leaflets. The endothelial covering undergoes the same changes 
as that of the arteries including ulceration and deposit of fatty 
and calcareous plaques. The valves may be thickened and 
contracted, appearing Hke misshapen pedicles which diminish 
the size of the orifice but cannot fully close it. The distorted 



304 PATHOLOGICAL OLD AGE 

valves may take different forms and produce various shaped 
orifices, increasing or diminishing the size of the openings, 
partially blocking them or permitting any degree of regurgita- 
tion. Calcification is a late degenerative change. When this 
occirrs decompensation rapidly ensues and the impairment to 
the circulation caused by the weakened heart produces rapid 
degeneration in other organs and tissues. 

Before taking up the valvular lesions in detail a few diagnostic 
points applicable to senile cases will be given as follows. 

A murmur or abnormal sound is heard when the blood is sent 
against a resistance at the orifice or when, in the rebound, the 
blood returns to a cavity through an incompletely closed orifice, 
or if the valves are roughened. In the first case the valve does 
not open completely and there is an obstruction or stenosis. 
This is due to a thickened or distorted valve or to a growth at the 
orifice. In the second case the valve does not close completely 
and we get a regurgitation or as it is usually called incompetence 
or insufiiciency. This may be due to a defect of the valve or it 
may be due to a dilatation of the cavity or of the aorta, whereby 
the orifice is stretched. The diagnosis of a valvular lesion is made 
primarily by the location of the murmur and the time of its oc- 
currence in the cardiac cycle. The obstructive murmurs are 
heard loudest over the valve, the regurgitant murmurs are heard 
loudest back of the valve in the cavity into which the blood re- 
bounds, the former are carried forward in the direction of the 
flow, while the latter are carried in the direction of the rebound. 
We can thus localize mitral murmurs about the apex, aortic mur- 
murs near the base to the right or left of the sternum and tri- 
cuspid murmurs behind the middle of the sternum. Pulmonic 
murmurs and tricuspid stenosis are extremely rare, and occur 
only when, through loss of compensation and myocardial degen- 
eration, all the valves break down. In point of time the aortic 
stenosis occurs during the systolic contraction, while aortic 
regurgitation occurs after the blood has left the heart and a 
small quantity is forced back by the contraction of the aorta. 
This occurs during diastole The auricles contracting imme- 
diately before the ventricles, a mitral or tricuspid obstruction 
sound would occur therefore immediately before the systole or 
in the presystolic period. A mitral or a tricuspid insufficiency 
permits the return of blood from the ventricle during the con- 



VALVULAR LESIONS 305 

traction of that chamber, therefore the murmurs of these lesions 
occur during the systolic period. Abrahams has shown how the 
valvular lesions affect the pulse when the arm is held in different 
positions. In aortic regurgitation, if the arm is raised in a 
vertical position, the jerking, collapsing pulse is felt at an early 
stage of the disease and this variety of pulse remains throughout 
this disease. The pulse in aortic stenosis is slow and weak and 
it does not change in whatsoever position the arm is placed. In 
mitral stenosis the pulse is weak and if the arm is held in a 
vertical position over the head the pulse may disappear. In 
mitral regurgitation the pulse is weak, when the arm is held in a 
vertical position and reappears strongly when held in a horizontal 
position. When compensation is lost the pulse in mitral disease 
disappears entirely upon raising the arm over the head. 

In radial arteriosclerosis these characteristics may not ap- 
pear, and the radial pulse may be so weak in any position as to 
be hardly appreciable. Errors may occur if two murmurs are 
heard at the same time. The only diastolic murmur occurring 
in the aged is the aortic regurgitant murmur. The aortic 
obstructive and the mitral and tricuspid regurgitant murmurs 
occur during the systole, but the aortic murmur is never heard at 
the apex, the mitral murmur is heard over the apex and to the 
left and is often heard at the back, the tricuspid is heard to the 
right of the sternum. As diastole begins with the beginning of 
the second sound we must be certain about the two sounds and 
if there is any doubt as to which is the first and which the second 
we must find the apex beat or the carotid pulse, thus determining 
the systole. The radial pulse is useless for this purpose. An 
hour-glass murmur, one which is heard loudest at one valve, 
gradually growing weaker to a certain point, then again increas- 
ing in intensity as we approach another valve, indicates that the 
two valves are diseased. In the aged this happens most fre- 
quently in aortic obstruction and mitral regiu-gitation. 

Presystolic murmtu"s are heard best when the patient is sitting 
or standing up, systoHc murmurs are heard best when the patient 
is lying down and the mtn-miu* of tricuspid regurgitation can 
sometimes be heard only in Stern's postture, lying down with the 
head slightly lowered so as to stretch the vessels of the neck. 
Diastolic mtu-murs are not affected by position. 

All murmtu-s heard in the region of the heart are not due to 



3o6 PATHOLOGICAL OLD AGE 

valvular lesions nor do all cardiac murmiirs imply diseased 
valves. There may be a relative insufficiency in which the orifice 
is enlarged so that the valve cannot close it completely, yet the 
valve will be sound. The Austin Flint murmur sometimes heard 
near the apex in aortic regurgitation may simulate the murmur 
of mitral stenosis and is in the locality in which mitral miu-murs 
are usually heard, yet it has apparently no connection with 
mitral disease. 

Functional or accidental murmurs are infrequent in the aged, 
as the probable cause, pressiu-e upon or suction of the over- 
lapping edges of the lungs by the cardiac contractions, does 
not prevail where the lungs are atrophied. In anemia or 
debility, leakage may occur through the mitral or tricuspid 
valve. This real, though temporary relative insufficiency is 
not an organic defect. The pericardial friction sounds and 
cardiorespiratory murmurs are affected by the respiration and 
there is a history pointing to the underlying cause. 

AORTIC REGURGITATION 

The author has found this one of the most frequent valvular 
lesions in the aged, while other observers consider mitral 
regurgitation to be the most prevalent one. Aortic regurgitation 
is in some cases a relative insufficiency caused by dilatation 
of the orifice, more often, however, the fault lies in the valve 
itself. 

Etiology. — Relative insufficiency is due either to a dilata- 
tion of the aorta or aortic aneurysm just above the valve, 
thereby stretching the aortic ring, or to dilatation of the left 
ventricle. In insufficiency due to valvular defect the cause is 
either the general cause of ageing and arteriosclerosis affecting 
primarily the valve, or it may arise from the extension of an 
arteriosclerosis of the aorta or from senile endocarditis. 

Pathology. — In relative insufficiency the valve is not affected. 
The orifice is distended, and when the valve closes, the edges 
do not approximate. When the fault lies in the valve the 
cusps thicken, harden, contract and shrivel up, or they may 
adhere to the endocardium. The left ventricle receives normally 
from the auricle the quota which will completely fill it. When 
more blood enters the heart after rebounding from the aorta 
the muscle fibers become stretched and the cavity dilates. 



ii 



AORTIC REGURGITATION 307 

As long as the hypertrophy is sufficient to compensate for the 
disturbed circulation, no further change occurs. When the 
limit of functional ability is reached and decompensation begins, 
dilatation proceeds rapidly, an insufficient supply of blood 
reaches the coronaries and myocardial degeneration sets in 
through impaired nutrition. The cordae tendinae shrink and 
cause relative insufficiency of the mitral valve while the valve 
itself is weakened through the extra strain placed upon it by 
the greater amount of blood in the ventricle. It also degenerates 
primarily from senile involution or secondarily from extension 
of senile endocarditis. This causes pulmonary and venous 
engorgement with the consequent train of symptoms described 
in cardiac dilatation. 

Symptoms. — There may be no subjective symptoms while 
compensation is complete, though objective symptoms and 
physical signs are manifest. A pathognomonic symptom is 
the pulse, called Corrigan's or water hammer pulse. The 
increased force required to send an excessive amount of blood 
from the heart produces a strong, full pulse, but as some of the 
blood returns to the ventricle the pulse strength drops rapidly 
and fades away. This characteristic can be brought out very 
early in the disease, if the arm is lifted above the head, allowing 
the force of gravity to aid in the rapid emptying and collapse 
of the radial artery. Other early symptoms are increase in 
carotid pulsation and the usual symptoms of cardiac hyper- 
trophy. When decomposition sets in there are the symptoms 
of cardiac dilatation, with dyspnea, precordial distress, and the 
symptoms of venous engorgement. 

The earHest physical sign is usually a visible carotid pulsa- 
tion. The heaving impulse given to the chest is not as marked 
in aged individuals as in earlier life owing to the rigidity of the 
chest wall, but there may be a pronounced bulging. The apex 
beat may be weaker and more diffused. Capillary pulsation 
is usually an early sign and may be demonstrated by rubbing 
the thumb nail across the forehead, when the hyperemic line 
will redden and then become paler with each pulsation. Per- 
cussion gives little information of value, as the heart is usually 
hypertrophied in the aged, but in advanced cases the hyper- 
trophy and consequent dilatation are greater than in any other 
cardiac disease. 



3o8 PATHOLOGICAL OLD AGE 

A diastolic murmur in the aged is virtually pathognomonic 
of aortic regurgitation. Other diastolic murmurs are rare in 
old people and can readily be distinguished from the murmur 
of aortic insufficiency. Pulmonary regurgitation which gives 
a diastolic murmur may ^set in when decomposition is complete 
and all the valves are involved. By this time the many con- 
fusing abnormal sounds heard in the chest, the diversity in the 
areas and direction of transmission, the arrhythmia and signs 
of profound pulmonary and circulatory disturbances, make a 
definite differential diagnosis impossible. Other diastolic mur- 
mtirs which might possibly occur in the aged are a cardio- 
respiratory murmtir and a venous hum, due to anemia. The 
former disappears when holding the breath, the latter disappears 
when slight pressure is made upon the jugulars. (Prolonged 
pressure may induce cerebral hyperemia and hemorrhage.) 
A diastolic pericardial friction sound may be heard at the base 
of the heart in acute adhesive pericarditis, but it is incidental 
to the pericarditis, the sound is usually double and the symp- 
toms of aortic disease are absent. 

Mitral stenosis which gives a presystolic murmur may be 
mistaken for aortic regurgitation. The former immediately 
precedes the first sound, the latter immediately follows the 
second sound. Mitral stenosis is rare in the aged except as a 
secondary and late sequel to aortic disease, mitral regtirgitation 
or general arteriosclerosis. 

Numerous other symptoms and signs may occur in aortic 
regurgitation, but they add nothing to the determination of 
the diagnosis of this disease in the aged. The so-called pistol- 
shot sound, a systolic sound heard over the arteries, especially 
over the femoral, and caused by the sudden filling of the empty 
vessel, is rarely appreciable. Duroziez' sign, a diastolic mur- 
mur heard over the larger vessels when pressure is made by the 
stethoscope is rarely heard. Traube's sign, a double murmur 
heard over the carotid and femoral, is rare and indistinct. The 
Flint murmur, a faint rumble heard at the apex immediately 
after the murmur of the aortic regurgitation, is occasionally 
met with, but if occurring as a presystolic murmur it can hardly 
be distinguished from the murmur of mitral stenosis except by 
the absence of signs of pulmonary engorgement. The prognosis 
is good as long as the hypertrophy maintains full compensation. 



AORTIC STENOSIS 309 

In most cases the excessive work imposed upon the heart in 
sending the blood through sclerosed vessels brings it sooner or 
later to the limit o: its functional ability, while the internal 
pressure in the left ventricle produced by an excess of blood 
causes dilatation. The mitral valve becomes involved and the 
disturbance in the pulmonary and circulatory systems hasten 
degeneration of other organs. While the mitral insufficiency 
is a temporary safety valve for the dilated ventricle by relieving 
the over distention, it causes pulmonary engorgement. 

Dilatation of the aorta is generally associated with aortic 
regurgitation, and mitral regurgitation is found in almost every 
advanced case. This is generally followed by mitral stenosis 
and aortic stenosis, later by tricuspid regurgitation and other 
valvular defects. The sequence may, however, be altered in 
myocardial degeneration. 

Treatment. — See Treatment of Cardiac Lesions. 

AORTIC STENOSIS 

Aortic stenosis, though occurring quite frequently in old 
age, is always a complication of some other valvular lesion, 
generally aortic regurgitation. Cabot reports that out of over 
250 autopsies in cases of valvular disease there was not a single 
uncomplicated aortic stenosis but there were 29 occurring with 
aortic regurgitation. 

Etiology. — This disease in advanced age is due to extension 
of atheroma from the aorta, extension of senile endocarditis, or 
atheromatous deposits about the aortic ring, or it may occur as a 
degeneration originating in the valve itself. 

Pathology. — The cusps become thick and rigid and some- 
times calcareous plates form under the valve, which becomes 
misshapen and obstructs the free passage of the blood out of the 
ventricle, while the cusps, not closing completely, allow blood 
to return from the aorta, thus causing an insufficiency. This 
is the usual condition of the aortic valve when diseased. In 
some cases the margins of the cusps adhere to each other, thus 
reducing the opening. Occasionally there are fibrin deposits 
upon the valves which prevent the complete opening of the 
cusps, or which present rough edges or free ends to the stream. 
Hypertrophy is invariably present and late in the disease there 
is dilatation. 



3IO PATHOLOGICAL OLD AGE 

Symptoms. — The pathognomonic symptom of aortic stenosis 
is the pulse, ''pulsus rarus, parvus tardus," infrequent, small and 
slow, in contrast to a strong apex beat. There is a systolic 
murmur, heard best in the third intercostal space close to the 
right margin of the sternum, the sound being carried upward 
toward the neck. If a murmur is heard at the apex also it is 
due to another valvular lesion. The area of cardiac impulse is 
increased, but the apex impulse is indistinct, the force of the 
heart is increased also, and a purring thiill is felt over the 
heart, especially marked over the valve, and sometimes felt 
in the carotids, and there is an increased area of dulness 
to the left and downward showing hypertrophy of the left 
ventricle. 

Other conditions, which give a similar thrill and murmur, 
are aortic aneurysm and aneurysm of the innominata, and 
these can readily be differentiated by the absence of the diastolic 
shock, tumor, abnormal pulsation, pain, symptoms of pressure 
upon the trachea, bronchi or recurrent laryngeal nerve, etc., 
found in aneurysm, and by the presence of the characteristic 
pulse. A diffuse dilatation of the aorta may give a systolic 
murmur, but this condition is almost always associated with 
aortic regurgitation and an increased area of dulness above the 
base. Roughening of the aortic valve may give a systolic 
murmur over the valve. This is distinguished from the mur- 
mur of stenosis by the accentuation of the second sound of the 
heart, while in stenosis this sound is faint. If the intima of the 
aorta is roughened there may be a systolic murmur at the base, 
but there is no thrill and the characteristic pulse is absent. 
Functional systolic murmurs are rare in the aged and they do 
not present any of the other signs of aortic disease. Pulmonary 
stenosis occurs only when all the valves are involved in decom- 
pensation. The distinguishing signs between aortic and pul- 
monary stenosis are useless in the aged, as the latter never occurs 
without the aortic and other cardiac lesions. 

Mitral regurgitation has a systolic murmur which is heard 
most distinctly over the apex, but there is no thrill nor the 
characteristic weak slow pulse. Tricuspid regurgitation has a 
systolic murmur but none of the other signs of aortic stenosis 
and there is generally a jugular pulsation and pulmonary dis- 
turbance. Aortic stenosis is almost invariably associated with 



MITRAL REGURGITATION 3II 

aortic insufficiency and the prognosis depends upon the prog- 
nosis of the latter disease. 

For Treatment see Cardiac Lesions. 



MITRAL REGURGITATION 

Mitral regurgitation is generally either a degenerative con- 
dition, or it is a relative insufficiency secondary to dilatation. 
In many cases both conditions prevail. 

Etiology. — Relative insufficiency occurs when myocarditis 
or dilatation stretches the orifice so that the flaps cannot ap- 
proximate fully. This generally occurs after aortic regurgita- 
tion and this combination of valvular lesions, aortic and mitral 
regurgitation, is the first result of decompensation following 
the primary lesion. In rare cases the senile degenerative 
process begins in the valve, more often it follows an extension 
of senile endocarditis or shortening of the cordse tendinas. The 
etiological factors which make it the most prevalent lesion in 
earlier Hfe, rheumatism and excessive physical activity, rarely 
appear in later life. 

Pathology. — The valve becomes thickened, hardened and 
shortened. The cordae tendinas thicken and shorten and drag 
down the flaps. The papillary muscles grow thinner. The 
valve flaps may adhere to the ventricular wall and thus become 
immobilized. The excess of blood in the auricular chamber 
causes the walls of that chamber to dilate. The walls at the 
same time hypertrophy and for a time compensation is main- 
tained, but the dilatation proceeds faster than the hypertrophy 
and the latter soon reaches the limit of its capacity. After 
decompensation sets in, the blood is dammed back into the 
lungs and later the right side of the heart becomes affected. 
There is first hypertrophy, later, dilatation of the right ventricle, 
tricuspid regurgitation, right auricular hypertrophy, then dila- 
tation, obstruction to the venous circulation, with degenera- 
tion following passive congestion of the liver, kidneys, stomach, 
spleen, etc. Late in the disease, hypertrophy, then dilatation 
of the left ventricle occurs, and every valve and chamber of the 
heart is affected. 

Symptoms. — There are no early symptoms or signs of mitral 
regurgitation except a systolic murmur at the apex, the sound 



312 PATHOLOGICAL OLD AGE 

being carried to the back behind or below the angle of the scap- 
ula. The apex beat is found more to the left than normal and 
the area of dulness is increased downward and to the left. The 
second sound of the heart is more intense over the pulmonic 
valve. When dilatation and decompensation ensues, there 
follows the train of symptoms described under cardiac dilata- 
tion. The earHest of these symptoms is cardiac asthma, 
dyspnea, palpitation and sHght cyanosis upon exertion, and 
sometimes even without exertion. Later the dyspnea and 
cyanosis are constant and venous engorgement of the liver, 
kidneys, brain and stomach follow. The distiu-bance to the 
pulmonary circulation produces dyspnea, cyanosis and a cough 
with watery and occasionally blood-stained expectoration. 
The Hver becomes enlarged, there is a feeling of w^eight and pain 
in the right hypochondrium and there may be jaundice. Kidney 
involvement is shown in scanty high-colored urine, sometimes 
albuminous and occasionally presenting casts. Cerebral hyper- 
emia is produced with headache, vertigo, occasional stupor 
or even delirium. There is gastric and intestinal catarrh and 
usually hemorrhoids. Later, as a result of the circulatory 
disturbance, dropsy and anasarca set in. The pulse becomes 
weak and, upon excitement, it is irregular in rhythm and force. 

Diagnosis. — The only other systolic murmiu-s that may be 
confused with that of mitral regurgitation are functional mur- 
miurs and the miu-mur of tricuspid regurgitation. Functional 
murmurs are rare in the aged, they are faint or absent while 
in the upright position and are transmitted to the back. The 
murmurs of aortic stenosis and roughening of the aortic valve 
are heard best over the valve and are not transmitted to the 
back. Aortic stenosis has a characteristic pulse which is 
absent in the mitral disease. 

Tricuspid regurgitation gives a miu-mur so similar to that 
of mitral regurgitation that it is often impossible to differen- 
tiate between them and as the tricuspid lesion always occurs 
after the mitral lesion it is generally overlooked. Tricuspid 
mtumiu-s are not heard in the back and their maximum in- 
tensity is to the right of the sternum, but they may be heard 
distinctly at the apex. These points are, however, useless 
for the determination of the diagnosis, as the mitral lesion is 
invariably present. Jugular pulsation, an early ■ S3^mptom of 



MITRAL STENOSIS 313 

tricuspid regurgitation, does not occur in uncomplicated mitral 
regurgitation. If it does appear in mitral disease it is an 
evidence of tricuspid involvement. 

Treatment is given under Cardiac Lesions. 

MITRAL STENOSIS 

Mitral stenosis is a degenerative process in which the 
shrunken and thickened flaps diminish the size of the auriculo- 
ventricular opening. 

Etiology. — The causes prevailing in earlier life do not prevail 
in old age and when the disease occurs in earlier life the in- 
dividual does not live long enough to grow old. Mitral stenosis, 
when occurring in the aged, is almost always due to a degenera- 
tive process originating in the valve itself or carried to the 
flaps by extension from senile endocarditis. It may follow 
Bright's disease and Vinay reported a case in which a deposit 
of calcareous matter about the ring caused a diminution in 
the size of the orifice. 

Pathology. — The flaps become thickened, hardened and 
shrunken. The shrinking of the valves prevents complete 
apposition of the edges with consequent mitral insufficiency. 
The button-hole slit caused by adhesion of the edges of the valve 
is rarely found in advanced life. This adhesion may be due 
either to a change in the blood which permits fibrin to be 
deposited upon the edges with consequent agglutination of 
these deposits, or else to an irritation with following adhesive 
inflammation of the edges, from blood toxins. The latter 
cause would also explain the presence of endocarditis wher- 
ever we find the button-hole slit. The only disease causing 
such irritation in old age is chronic nephritis and it is only 
when this disease is present that the button-hole slit is found. 
When the stenosis progresses and mitral regurgitation ensues, 
there follow hypertrophy and dilatation of the left auricle, 
with blocking of the pulmonary circulation and with the train 
of disorders that follow pulmonary engorgement. 

Symptoms. — Mitral stenosis is a lesion that may exist for 
years without giving any marked symptoms or signs. Among 
the earliest of the suggestive symptoms is irregularity of the 
heart in rhythm and force upon exertion which rapidly subsides 



314 PATHOLOGICAL OLD AGE 

after resting. Occasionally a purring thrill may be felt at the 
apex just preceding the apex beat. As the disease is almost 
invariably associated with mitral insufficiency, the symptoms of 
stenosis may be completely masked by those of the insufficiency 
and as soon as decompensation sets in there are the usual 
symptoms of pulmonary, and later, venous engorgement. The 
only symptom pointing to mitral stenosis is frequent hemop- 
tysis. The murmur of mitral stenosis is almost pathognomo- 
nic. It is a presystoHc murmur, loud, long and rumbHng, end- 
ing with the first sound of the heart, and heard in a limited 
area about the apex. The only other murmur which may 
possibly be mistaken for it is the Flint murmur, which occurs 
occasionally in aortic regurgitation and tricuspid stenosis, a 
very rare condition, unknown in the aged. 

The mtn-mur of mitral stenosis is frequently absent in the 
early stage of the disease or it may appear temporarily dur- 
ing or immediately following exertion. It also disappears after 
decompensation sets in. The ptirring thrill about the apex can 
sometimes be felt before the murmur appears and it, too, dis- 
appears as soon as decompensation occurs. It is presystolic, 
and ends with the apex beat. 

The first sound of the heart is short, loud and snapping; 
the pulmonic second sound is accentuated and is sometimes 
double. When decompensation occurs or when other valvular 
lesions exist, the short, sharp first sound may be the only sign 
determining the presence of a mitral stenosis. 

The prognosis of mitral stenosis in the aged depends upon 
the mitral regurgitation present. The two may exist for years 
without giving distress, but sooner or later decompensation 
sets in and carries the patient rapidly to the fatal issue. 

Treatment. — See Treatment of Cardiac Lesions. 

TRICUSPID REGURGITATION 

Tricuspid insufficiency, though rarely diagnosed, is a fre- 
quent sequel to mitral disease in the aged. In these cases it is 
a relative insufficiency, caused by a dilatation of the right ven- 
tricle with stretching of the auriculo-ventricular orifice. A 
degeneration of the valve is possible, but out of over 400 au- 
topsies made in Guy's Hospital in which tricuspid insufficiency 



COMBINED VALVULAR LESIONS 3 1 5 

was found, there was not one showing valvular degeneration. 
In some cases it was due to myocarditis or to pulmonary disease. 

Symptoms. — The symptoms are referable to venous engorge- 
ment. Specially marked in this disease are systolic jugular 
pulsation or vibration, distention of the superficial veins of the 
upper part of the body when the patient coughs or strains, and 
cyanosis which is more pronounced when the patient is in the 
horizontal position. When in this position cerebral hyperemia 
occurs and may be of such extent as to produce cerebral com- 
pression with stupor and coma. Symptoms associated with 
passive congestion in other organs appear, especially in the 
liver and kidneys. A pulsation over the liver is pathognomonic 
of tricuspid regurgitation, but it is often absent. A jugular 
pulsation or vibration may be normal or due to other causes. 
If a vein, after being temporarily emptied by stroking from 
below upward, immediately fills up from below, it is pathogno- 
monic of tricuspid regurgitation. If it does not fill from below, 
the cause of the pulsation is not due to this disease. Tricuspid 
regurgitation presents definite physical signs but in the aged 
this condition is almost invariably associated with mitral 
regurgitation and the more marked signs of the mitral disease 
may mask the signs of the tricuspid lesion. There is a systolic 
murmur near the fifth left costal cartilage, not loud, and often 
absent. In some cases it may be brought out in Stern's posi- 
tion, i.e., the patient lying horizontally with the head slightly 
lowered. The area of dulness is increased to the right of the 
sternum. 

The diagnosis, in the absence of the murmur, depends upon 
the pulmonary symptoms, dyspnea and cyanosis which become 
worse in a horizontal position. Jugular and epigastric pulsa- 
tion confirm the diagnosis. 

Treatment. — See Treatment of Cardiac Lesions. 

COMBINED VALVULAR LESIONS 

It frequently happens that two or more valvular lesions 
exist at the same time. One valvular lesion may cause a defect 
in another, or the same valve may produce both stenosis and 
regurgitation. Such combined valvular lesions produce a 
variety of symptoms and signs, some of which may modify 
others. 



3l6 PATHOLOGICAL OLD AGE 

The most frequent of the combined lesions is aortic regurgi- 
tation and a relative mitral insufficiency produced by the ven- 
tricular dilatation following the aortic defect. Tricuspid rela- 
tive insufficiency follows a mitral regurgitation. If there is a 
mitral stenosis, a mitral regiirgitation accompanies it. Aortic 
stenosis is generally associated with aortic regiu-gitation or is 
followed by mitral regurgitation. When compensation is lost 
there may be aortic, mitral and tricuspid lesions with murmurs 
all over the chest, and arrhythmia, irregular pulse and irregular 
cardiac impulse, making it impossible to determine what valves 
are affected or how. 

In aortic and mitral regurgitation a murmur is heard after 
each sound, the murmur after the first sound being most distinct 
at the, ^apex, the diastolic murmur being loudest at the third 
costo-sternal articulation. The murmurs are transmitted down- 
ward and to the left. The water hammer pulse is modified; it 
is weaker and does not fade away as rapidly as in the uncom- 
plicated aortic regurgitation. Capillary pulse may be absent. 
In aortic stenosis and regurgitation there is a double murmur 
over the aortic area, one after the first sound, the other one fol- 
lowing the second sound of the heart, the first being transmitted 
upward toward the neck, the other downward toward the 
xiphoid cartilage. The pulse is modified as in mitral compHca- 
tion, capillary pulsation is diminished and the pulsation in the 
peripheral vessels may be absent. The thrill of aortic stenosis 
may be absent also. 

In double mitral disease the murmur precedes and follows 
the first sound of the heart. The presystolic murmur is often 
absent and must be brought out by some exertion such as a 
fast walk or jump. If once heard the diagnosis is certain and as 
mitral obstruction is always associated with regurgitation, the 
symptoms of the latter disease need not be sought for. 

Mitral obstruction does not occur with aortic disease. Aor- 
tic stenosis may be associated with mitral regurgitation. There 
is a systolic hour-glass murmur in this case, the one maxi- 
mal point being at the apex, the other at the second right 
costo-sternal articulation or just below it with a vanishing point 
at the fourth left costo-sternal articulation. The pulse of aor- 
tic stenosis is not altered, but the thrill is weakened. 

Mitral regurgitation and tricuspid regurgitation are often 



TREATMENT OF CARDIAC LESIONS 317 

found together but it is necessary to determine the presence of 
the tricuspid lesion alone. The murmurs of the two occur at 
the same time their areas of conductivity overlap and their 
points of maximum intensity are so close together that errors 
are very liable to occur. The diagnosis must be made by the 
signs of mitral regurgitation and by the symptoms of the tri- 
cuspid disease, like jugular pulsation, etc. 

TREATMENT OF CARDIAC LESIONS 

In the treatment of cardiac lesions in old age this rule is 
imperative: No interference while compensation is complete. 
Proper hygiene and the avoidance of sudden or prolonged 
strain must be observed to prevent rapid loss of muscle tone, 
and there should be no medicinal treatment as long as the 
heart maintains its strengh and regularity. 

The aged person should continue to take exercise and may 
continue at his ordinary vocation if it does not involve sudden 
strains, but the moment dyspnea or palpitation appears he 
must stop and lie down. He must guard against straining at 
stool and should avoid foods which tend to produce flatulency. 
Intense mental concentration and powerful emotions, even if 
pleasiu^able, are injurious, while shock may cause sudden death. 

Failing compensation comes on gradually and its earliest 
symptom is slight dyspnea without previous exertion. As soon 
as this is noticed the patient should go to bed and remain there 
for at least a week. Compensation is occasionally restored by 
prolonged absolute rest. In administering drugs in cardiac 
disease of the aged, there are a few general rules that must be 
observed. Heart tonics should not be given until they are 
required to overcome weakness, and heart stimulants should 
never be given except in an emergency or to counteract rapidly 
acting cardiac depressants. Vasoconstrictors must be used 
cautiously, as the sclerosed vessels may not be able to with- 
stand increased pressure. Heart depressants are of service 
only in hypertrophy without valvular lesion. Drugs are rarely 
required in this condition unless the hypertrophy is extensive 
enough to cause palpitation and active cerebral congestion. 
In this case we can use aconite in i -minim doses several times a 
day until the heart action is lowered. Veratrum viride or gel- 



3l8 PATHOLOGICAL OLD AGE 

seminum in 5 -minim doses of the tincture can be given in the 
place of aconite. (Chloral hydrate should not be used in old 
age.) In some cases of aortic stenosis aconite or veratrum will 
steady the heart but the drug must be stopped as soon as an 
effect is produced. Digitalis, the most valuable drug in the 
pharmacopeia, is dangerous in senile conditions. It is contra- 
indicated in aortic disease, myocardial degeneration and in cases 
of high blood pressure. When given by mouth the response in a 
stronger pulse appears about twelve to thirty-six hours later; 
therefore, it is useless when quick action is desired. It must be 
noted that its action is cumulative. The author has seen two 
cases of apoplexy following the hypodermic use of digitalis 
preparations in threatened heart failure. If the heart is rapid 
and weak tincture of strophanthus should be given in 2- to 4- 
minim doses. Adonin in i/8-grain doses several times daily 
can be used in aortic regurgitation. Tincture of cactus grandi- 
fiorus in 5 -minim doses and of convallaria 5- to lo-minim doses 
can be given in place of digitalis and strophanthus. The fre- 
quent lack of success when using these drugs must be ascribed 
to their poor quality. More positive results are obtained when 
using their glucosides, convallamarin and cactin. The special 
indication for spartein is a slow, weak heart, such as occurs in 
decompensation following aortic stenosis. This should be used 
in 1/2- to 2 -grain doses until the heart beats respond with 
greater strength and frequency, when it must be discontinued. 
It may be combined with i/50-grain strychnia. The nitrites, 
amyl nitrite, spirit glonoin and sodium nitrite are powerful 
vasodilators and should be used only to relieve cardiac spasm, 
an overdistended heart or poor peripheral circulation. They 
should not be used if the face is flushed or where there is cerebral 
hyperemia. The amyl nitrite used in 3- to 5-minim doses by 
inhalation is of service in angina pectoris, cardiac asthma and 
syncope. In threatened heart failure nitroglycerin in i/ioo- 
grain dose can be used hypodermically combined with 1/30- 
grain strychnine and i/ioo grain digitalin. For prolonged ac- 
tion the nitrite of soda can be given in 1/6- to i -grain doses 
every four hours. 

Other emergency drugs are to be given only where there is 
danger of cardiac exhaustion; these are carbonate of ammonia 
in 5 -grain doses, compound spirits of ether 30 minims, or sul- 



TREATMENT OF CARDIAC LESIONS 319 

phuric ether hypodermically in 20-minim doses, camphor 5 
grains in oily solution hypodermically, and alcohol. The most 
rapid action is obtained from the hypodermic use of ether but 
the action is evanescent. Strychnine should not be used before 
decompensation sets in, as it simply hastens decompensation 
and it should be used only as an emergency drug, being a cardiac 
stimulant and not a cardiac tonic. The distressing symptoms 
accompanying cardiac lesions require treatment distinct from 
that of the disease. 

For dyspnea, if there is no contraindication to the nitrites, 
the nitrite of amyl gives most prompt relief. Morphine or 
dionin in i/8-grain doses is of service for dyspnea occurring at 
night and preventing sleep. However, neither the nitrites nor 
morphine should be used continuously. For prolonged treat- 
ment the tincture of cimicifuga in i-dram doses, combined with 
arsenic in the form of Fowler's solution in doses of 3 -minims, 
should be used three times a day. The arsenic must be discon- 
tinued when its physiological symptoms appear. 

Cardiac asthma will generally yield to 1/2-dram doses of 
compound spirits of ether. Palpitation or arrhythmia will 
sometimes subside upon a hypodermic injection of 1/120 grain 
of atropia. If it occurs frequently the bromides may be given. 
The selection of the drug must depend upon the condition of 
the heart, using sedatives in hypertrophy, the nitrites if there is 
high blood pressure, and morphine, spartein, strychnine, ice- 
bags, etc., as indicated. In some cases when decompensation 
sets in suddenly with dyspnea and palpitation, immediate rest 
in bed, remaining there for several days while eating and drink- 
ing sparingly, will restore compensation. 

In insomnia a hot foot bath should be tried. If this fails we 
can use 5 to 10 grains of veronal and if there is considerable 
mental agitation it should be combined with 3 grains of mono- 
bromated camphor. No Chloral! Morphia may be used if 
veronal fails, but it must be combined with atropin to prevent 
paralysis of the respiratory centers. 

Nothing will relieve the cyanosis except the inhalation of 
oxygen and this is of service only while it is being used. It 
should be employed occasionally in cyanotic cases to improve 
the condition of the blood, and to give temporary relief to the 
lungs and thus indirectly to the brain. Edema, which occurs 



320 PATHOLOGICAL OLD AGE 

late, unless associated with nephritis, is difficult to treat in 
the aged. A salt-free diet is the most important measure. 
For this purpose malted milk with milk or water in small quan- 
tities, just sufficient to supply the actual needs of the system, 
should be taken. Mild diuretics should be used. In cardiac 
dropsy calomel in i/io-grain doses every three hours and 4 
drams potassium bitartrate every second day will produce free 
diuresis and catharsis. The legs should be elevated and when 
the edema disappears they should be bandaged, but the band- 
ages must not be too tight, as they might compress sclerosed 
vessels and obliterate them. Puncturing the edematous limbs is 
useless in the dropsy due to tricuspid regurgitation as edema 
reappears in a few days, but it may become necessary to punc- 
ttire an abdominal dropsy. If chronic nephritis complicates 
the cardiac disease diuretics should be used cautiously, lest they 
increase the irritation to the kidney. It is better in these cases 
to try to reduce the edema by a salt-free diet and hydragogue 
cathartics, though the latter further impair the already im- 
poverished blood. 

The Oertel, Schott, and Nauheim treatments of heart 
disease are contraindicated in old persons. 

INTESTINAL OBSTRUCTION 

Partial obstruction is generally overlooked. It may be tem- 
porary or permanent, coming on slowly, and gradually increas- 
ing until complete occlusion occurs, or it may come on rapidly 
and, if due to impaction, is quickly relieved by removal of the 
offending substance. Complete occlusion comes on suddenly 
and unless soon relieved is rapidly fatal. The two conditions, 
stenosis and occlusion, will be described separately. 

Intestinal Stenosis 

Etiology. — The most frequent cause of temporary stenosis 
in later life is impaction with feces or gall-stones, while a per- 
manent stenosis is usually due to enteroptosis. Other causes are 
partial occlusion by growths within the bowel, or pressure 
from adjacent tissues upon the bowel; thickening due to in- 
flammation; contraction following such inflammation; contrac- 



INTESTINAL STENOSIS 321 

tion or growth of scar tissue over the site of an ulcer, or other 
lesion; kinks, volvulus, hernial constrictions, strangulation by- 
bands, adhesions to the peritoneum or mesentery, etc. Intus- 
susception is rare in the aged. Many of these causes may 
produce complete occlusion. Obstruction of the bowel may 
also be due to primary intestinal paresis or it may be due to a 
hemiplegia or paraplegia, the paralysis producing a paralysis of 
the intestines with consequent intestinal impaction. 

Symptoms. — The symptoms of intestinal obstruction depend 
upon the cause, degree and location of the obstruction. Com- 
plete obstruction will be considered in the chapter on Intestinal 
Occlusion. 

The location of the obstruction can often be determined 
by inspection and palpation, occasionally by other signs. If 
the duodenum or jejunum is blocked, the upper part of the 
abdomen is distended, digestive disorders occur early, vomiting 
may occur but it has no fecal odor. The urine is diminished or 
may be entirely suppressed. If obstructed in the region of the 
ileocecal valve the distention is greatest about the umbilicus 
and there is early fecal vomiting, or, if the obstruction is not 
severe or complete, there may be eructations of gas having a 
fecal odor. Peristaltic movements are often observable over 
the upper part of the abdomen. If the obstruction is in the 
large intestine the distention is at the sides and lower part of 
the abdomen. Obstruction due to impaction of feces or other 
substances, or to growths, can generally be diagnosed by the 
presence of a mass at the point of obstruction. A doughy mass 
which pits upon pressure and remains pitted is feces; a hard 
mass may be gall-stones or enteroliths ; a soft mass which does 
not pit is a growth. There may be impaction above a growth 
and the palpation signs of both will manifest themselves. An 
intestinal growth is movable with the bowel. If outside of the 
intestines it can be separated from the bowel. Complete 
occlusion of the large intestine can be determined by testing 
the capacity of that portion of the gut. The rectum holds 
normally three pints, the colon holds six quarts of water. If 
the entire amount can be introduced the obstruction is above 
the colon. 

Enteroptosis is frequently found in the aged in connection 
with ptoses of other abdominal viscera. It is due to weakened 



32 2 PATHOLOGICAL OLD AGE 

mesenteric attachment, flaccid abdominal walls, the weight of 
other displaced \-iscera, and possibly, to the weight of feces in 
the transverse colon. There are no clearly defined symptoms, 
and a positive diagnosis can be made only by radiography. 
The presence of a gastroptosis which can often be diagnosed 
by percussion and sometimes by inspection, associated with a 
sense of weight in the peh-is and with protrusion of the lower 
part of the abdomen, point to enteroptosis. There is also usu- 
ally backache, flatulence and frequent urination. It is sometimes 
possible to inflate the colon and its location can then be made 
out pro\'iding the abdominal walls are thin. The s3^mptoms 
pointing to partial obstruction in the displaced gut are constipa- 
tion, a powerful effort being required to force the stool out, 
occasional wateiy^ diarrhea containing scales of hardened feces 
which irritate the sphincter ani and distention of the bowels 
with gas and gurgling sounds in the lower part of the abdomen. 
There are often colicky pains, especially when making an 
effort to propel the feces, which are passed in a ribbon or pencil 
form, depending upon the shape of the stenosed aperture. 
Impacted feces can sometimes be felt in the right iliac fossa. 

Impactwn of feces generally occtirs in the descending colon. 
The mass can be felt and distinguished by its doughy consis- 
tency, the impress made upon the mass by the pressure of the 
finger remaining after the pressure is removed. There are 
coHck}" pains and tenesmus, abdominal distention by gas, 
constipation, stools occasionally passing in small scales and 
irregular lumps. In some case^ feces will force a channd 
through the impacted mass and will then come awa}' in small 
cylinders or balls. It is thus possible to have a daily stool with 
fecal impaction. Fecal impaction will give the constitutional 
s^'mptoms of autointoxication due to the reabsorption of fecal 
matter. Impaction by gall-stones, enteroliths and other foreign 
bodies generally occurs either at the ileocecal valve or in the 
upper part of the bowel. These may sometimes be felt as 
hard masses, not doughy, if the abdominal walls are thia and 
the intestines are not distended with gas. They produce 
considerable coHc and digestive disturbance but, imless they 
completely occlude the gut, they aUow the passage of semiliquid 
fecal matter, which reaching the lower bowel becomes formed 
and passes as a normal stool. If due to gaU-stones there will 



INTESTINAL STENOSIS 323 

be the symptoms pointing to them and bile will be found in the 
stools. EnteroHths and other foreign bodies give no distinctive 
signs by which their nature can be determined. The presence 
of a mass which cannot be pressed into or moved without drag- 
ging along adjoining tissues, eliciting a dull ache, but no sharp 
pain upon pressure, and giving the other symptoms of intes- 
tinal obstruction points to a foreign body partly occluding the 
intestines. The X-ray gives the most definite information. 
Growths may occlude the lumen of the bowel entirely or partly. 
Benign growths increase slowly, the symptoms are mild and 
may pass unrecognized until complete occlusion occurs. The 
intestines may accustom themselves to the increased pressure 
at the point of constriction and a compensatory dilatation 
opposite to the growth may result. In such cases the feces will 
appear ribbonlike. Malignant growths occur most frequently 
in the colon and rectum. They are readily diagnosed by 
their rapid progress, pain, cachexia, emaciation, involvement 
of other tissues, etc. Cicatricial stricture, and contractions, 
following inflammation cannot be specially diagnosed. They 
may be suspected where there is a pencil-shaped stool with 
the usual symptoms of partial obstruction, constipation with 
occasional stools, tenesmus, distention of the bowels, and 
colicky pains; these symptoms slowly increasing in severity. 
Adhesions to the peritoneum or mesentery may occur and give 
rise to partial obstruction of the gut with the ordinary symp- 
toms of that condition. There are no pathognomonic signs 
and the diagnosis must be made by the history of a former 
peritonitis and exclusion of other causes. The symptoms are 
usually mild, in some cases consisting only of an irregular 
constipation and occasionally a feeling of dragging upon the 
abdominal walls. Paresis of the intestines, if occurring suddenly, 
gives the symptoms of complete occlusion. A slow progressive 
I paresis begins with constipation, a gradually increasing difficulty 
\ in emptying the bowels and finally complete inability to move 
\ them followed by all the symptoms of complete occlusion. 
Kinks described by Lane may occur in any part of the intestines 
:' and produce a partial obstruction with chronic intestinal stasis. 
I This does not give the usual symptoms of obstruction, but the 
symptoms of a slow persistent antointoxication. It rarely 
proceeds to occlusion. Strangulation by bands, or hernial con- 



324 PATHOLOGICAL OLD AGE 

tractions, volvulus and intussusception almost always cause 
complete occlusion at once or within a few hours. 

Prognosis. — The prognosis of intestinal stenosis depends 
upon the cause. Fecal impaction can generally be removed 
and the obstruction disappears. Enteroptosis and adhesions 
to the peritoneum are permanent. They rarely produce 
much distress, rarely progress to complete occlusion and do 
not endanger life unless complete occlusion occurs. Benign 
growths and cicatricial stricture proceed very slowly to com- 
plete occlusion, while malignant growths rapidly close the gut, 
and such growths outside of the intestine, but in close juxtaposi- 
tion to it, will frequently involve the bowel. Obstruction due 
to other causes generally proceeds rapidly to complete occlusion. 

Treatment. — Medicinal measures are of service only in 
impaction of feces or gall-stones and for the temporary relief 
of distressing symptoms. If the fecal impaction exists in the 
colon, it may be softened by introducing a steady stream of 
warm water to which bicarbonate of soda, salt and glycerine 
has been added in the proportion of an ounce of each to the 
quart. The syringe should not be held high but the flow should 
be steadily maintained. The first part of feces passing away 
immediately after the enema are but the contents of the 
rectum and not the impacted mass. It is sometimes possible 
to reach the impaction with a rectal scoop but unless the whole 
mass can be scooped away the enema should be repeated until 
softening of the impacted feces has been accomplished. Massage 
is dangerous as injury to the intestinal wall can be easily 
produced by rough handling. An enema will not go beyond 
the colon and impaction beyond that must be reached by in- 
ternal medication. The fecal mass above the ileocecal valve be- 
ing fluid, impaction beyond that must consist of gall-stones or a 
foreign body. The following mixture has served well in such 
cases. Croton oil, i minim, castor oil 1/2 ounce and olive 
oil 31/2 ounces, taken in one dose to be repeated in four hours if 
necessary. A minim of oil of peppermint and half a grain of 
saccharin will disguise the smell and taste. If there is a rapid 
intestinal paresis, eserine in i/50-grain doses may be used 
hypodermically and repeated in three hours. Slow paresis 
must be overcome by the internal administration of persistaltic 
stimulants. 



INTESTINAL OCCLUSION 325 

In those cases in which there is a permanent or slowly- 
advancing partial occlusion, the most important measure is 
the regulation of the diet. The food should be easily digestible 
and leave little waste. Food containing much cellulose, seeds, 
rind, nuts and all other substances that cannot be completely 
converted must be avoided. If there has been a persistent 
constipation for several days, the predigested or readily con- 
verted foods should be used, but those containing a large per- 
centage of alcohol must not be taken. Malted milk is perhaps 
the best for prolonged use, but if a change is desired any of 
dry and non-alcoholic liquid foods can be used. If a cathartic 
is required castor , oil will act best. When complete occlusion 
occurs surgical intervention is necessary. 

Intestinal Occlusion 

Etiology. — Any cause that can produce partial intestinal 
obstruction may also produce complete occlusion, and many 
cases of partial obstruction proceed to complete occlusion. 
The most frequent causes of intestinal occlusion in the aged are 
cancerous growths and hernia. Volvulus and kinks are also 
frequent primary causes. Secondary causes are paralysis of 
the bowel associated with hemiplegia or paraplegia or following 
traumatism; peritoneal bands following peritonitis; scar tissue, 
completely closing the gut ; occasionally impaction, rarely intus- 
susception. 

Symptoms. — The symptoms of intestinal occlusion come on 
suddenly, with severe abdominal pain, which is at first colicky, 
but later becomes continuous. There is generally a history of 
constipation and in some cases the history will show a progres- 
sive partial obstruction which had reached the stage of com- 
plete occlusion. Shortly after the pain sets in, vomiting begins 
without nausea or straining. At first the contents of the 
stomach are ejected and afterwards a greenish or brownish bile- 
stained fluid. If the occlusion occiurs in the duodenum the 
ejected matter continues to be bile-stained but is not feculent. 
The fecal odor becomes more marked the farther along the 
gut the obstruction occurs. Tympanites begins about the 
second day and becomes extreme and feculent vomiting sets 
in about the third day. Collapse may occur as soon as the 



326 PATHOLOGICAL OLD AGE 

initial pain is felt. Usually, however, there is rapidly deepen- 
ing mental and physical depression, while collapse sets in only 
after the stercoraceous vomitus appears. 

In some cases, after the initial pain is felt, there is a watery 
diarrhea lasting a few hours then complete constipation. Tenes- 
mus is severe if the occlusion is in the large intestines and re- 
peated efforts at stool may being forth a little blood-stained 
mucus. The urine is either suppressed or it is scanty and con- 
tains indican and phenol. The mind is clear but there is an 
intense depression associated with the fear of dying. The 
Facies Hippocrates may appear within a few hours after the 
occlusion has occurred. A tumor can sometimes be felt at the 
site of the occlusion, while above that point the intestine bulges 
out so that it can be seen and felt. 

A cancerous growth is usually recognized long before it has 
produced complete occlusion of the gut. It is generally 
located in the colon or rectum; but occasionally a cancer of the 
mesentery will produce intestinal occlusion. Hernia may be 
either intraabdominal, or extraabdominal, umbilical, inguinal 
or femoral. It is impossible to diagnose an intraabdominal 
hernia except by exclusion. There is usually a history of trau- 
matism or peritonitis. The obstruction is generally in the 
small intestine, there is early fecal vomiting, no tenesmus, 
little or no meteorism and collapse occurs early. The extra- 
abdominal hernias are readily diagnosed and when strangu- 
lated they give the ordinary symptoms described. Volvulus 
may sometimes be recognized as a painful mass in the left iliac 
fossa, with intense remissive pain and marked early tympanites. 
It is comparatively rare. Kinks usually produce chronic intes- 
tinal stasis but may sometimes completely close the lumen of 
the gut and produce the symptoms of occlusion. There will, 
however, be a history of chronic constipation with autointoxica- 
tion lasting for many months. Any part of the intestine may 
be bound down and kinked, and a variety of symptoms refer- 
able to the intestinal tract are thus produced. Intestinal 
paresis is readily diagnosed by the associated paralysis. Cica- 
tricial stricture gives a history of duodenal, syphilitic, typhoid, 
or tubercular ulcer. The diagnosis of intestinal occlusion is 
simple after feculent vomiting has set in. Before this, the 
pain and abdominal distention may be mistaken for appen- 




Extensive protruding internal hemorrhoids. (From Gant's "Constipation,"} 



HEMORRHOIDS 327 

dicitis or peritonitis, but these diseases are accompanied by- 
fever and chills. Hepatic colic with constipation may simulate 
occlusion. The remission of pain, the jaundice, light-colored 
stools, location of colic, and the history, will distinguish the two. 
Treatment. — The treatment is purely surgical and should be 
undertaken as soon as the diagnosis of intestinal occlusion is es- 
tablished. Morphine and atropia may be given in the interim 
to relieve pain, and gastric irritation may be allayed by lavage, 
but nothing will relieve the obstruction except an operation. 
After collapse has occurred the case is hopeless. 



HEMORRHOIDS 

Hemorrhoidal Varix 

Etiology. — Hemorrhoids occur frequently in persons past 
maturity owing to the greater tendency to venous stasis and 
the weakening of the venous walls, which permit their dilata- 
tion. They are mostly internal piles which protrude through 
the relaxed sphincter and in most cases are due to pressure 
upon the hemorrhoidal veins by feces that are retained in the 
rectum. The underlying cause is that of rectal constipation. 
Stricture, and tumors of the rectum or of adjacent organs, 
which press upon the hemorrhoidal veins, may also cause hemor- 
rhoidal varix. 

Symptoms. — External piles are seldom sufficiently distres- 
sing to require medical attention. They appear as tumors, 
ranging in size from a pea to a marble, situated outside of the 
anal sphincter. When inflamed or eroded by the friction of 
the feces, or by scratching where there is an accompanying 
pruritus, the surface is reddened or ulcerated, and painful. In 
rare instances there will be a hemorrhage; more often there is 
pruritus and eczema around the tumor, and the skin becomes 
strongly pigmented and infiltrated. Internal piles in the aged 
generally protrude from the anus after defecation and some- 
times they remain permanently outside where the sphincter is 
lax. If returned within the rectum a slight strain will force 
them out again. They are readily recognized by their bluish 
appearance, doughy feel and motility under the mucous mem- 
brane which covers them. They are frequently inflamed, 



328 PATHOLOGICAL OLD AGE 

excoriated or ulcerated from the irritation of the feces, and 
when in this condition they are painful and bleed readily. 
There is often an itching eczematous area around them, the 
skin becomes anesthetic, infiltrated and pigmented and may 
become ulcerated. If the sphincter ani has retained its tonicity 
an internal hemorrhoid which had been forced out may become 
strangulated, the enclosed blood stagnates and coagulates 
there and the tumor will be converted into a cystic mass, or 
may become gangrenous. Defecation may cause an inflamma- 
tion about the base of the pile, and this periphlebitis, extending 
to the interior, produces a phlebitis. A proctitis, periproctitis, 
rectal abscess, anal fissures and fistulae are occasional complica- 
tions. The pain is usually not severe unless inflammation, 
erosion or ulceration occurs. When hemorrhage occurs it almost 
always accompanies defecation. In these cases there is generally 
a voluntary constipation, the patient fearing that defecation 
will produce pain or force out the pile. There may be tenesmus 
caused by irritation of the rectal wall, and there is sometimes a 
vesical irritation. In rare cases the pile is situated in the upper 
part of the rectum and is there more liable to become inflamed 
and to bleed. The cause or source of the hemorrhage may be 
a puzzle until an examination with the finger or proctoscope is 
made. It is hardly possible to mistake hemorrhoids for any 
other condition. Rectal and anal ulcers may bleed but do not 
present tumors. A carcinoma of the rectum is painful and 
rapid in its course; a polypoid bleeding growth does not have 
the color or consistency of the pile and breaks down upon 
slight friction. 

Treatment. — Hemorrhoids in the aged are usually less dis- 
tressing than in earlier life and may exist for years before a 
local pruritus, eczema or inflammation attracts the patient's 
attention to them. As soon as piles cause distress the annoying 
symptoms should be treated. For the pruritus we can follow 
the treatment suggested in the chapter on Senile pruritus and 
the eczema is to be treated as recommended in the chapter on 
this disease. Where there is an erosion or ulceration upon, or 
in the vicinity of a hemorrhoid, the surface should be covered 
with equal parts of subnitrate of bismuth and aristol over which 
a thick layer of unguent um petrolatum is to be appHed in order 
to protect the lesion from the irritation produced by the fecal 



BILIARY OBSTRUCTION 329 

discharges. If there is much pain in the pile a 2 per cent, co- 
caine ointment, using a lanoline base, should be used. This 
will generally give immediate relief, but if after two or three 
applications, the relief is not permanent the extract of bella- 
donna should be substituted for the cocaine. Inflammation 
is best treated by applications of ice water (not ice), and, if 
there is hemorrhage, adrenalin in i/io-per cent, solution will 
check it. Astringents will also check hemorrhage but they may 
produce a contraction of the anal sphincter and constrict the 
pile or, contracting the rectal wall, cause constipation. If 
operative procedure becomes necessary the choice of operation 
must be left to the surgeon. 

BILIARY OBSTRUCTION 

Etiolog)^ — Partial biliary obstruction occurs generally from 
impaction of gall-stones or inspissated bile in some part of the 
duct. Other causes of biliary obstruction are impaction by 
concretions or parasites, inflammation of the duct or of the 
duodenum about the mouth of the common duct, contraction 
following angiocholitis, growths in the ducts, or pressure upon 
the duct by a growth in neighboring tissues; aneurysm, fecal 
impaction or bands of adhesions. It is often impossible to 
determine the cause of the obstruction, but other causes than 
impaction by gall-stones or inspissated bile are rare. An 
angiocholitis may occur as an extension of an inflammation of 
the duodenum, or may be due to irritation following the passage 
of a gall-stone. In most cases it is caused by the invasion of 
microorganisms, the colon bacilli, streptococci and staphy- 
lococci being generally found in the bile passages and in the 
bile of patients. In angiocholitis the mucous membrane is 
thickened and covered with thick tenaceous mucus, and if due 
to infection the secretion is mucopurulent. The swelling of 
the membrane usually produces a partial occlusion, but it may 
entirely obliterate the lumen of the duct. 

There is no direct method of diagnosing angiocholitis nor 
can a presumptive diagnosis be made before jaundice appears. 
If symptoms of gastroenteritis precede the jaundice, there has 
probably been an extension of the inflammation into the duct. 
In this case there is a slowly increasing jaundice. Gradually 



330 PATHOLOGICAL OLD AGE 

all the symptoms improve and the jaundice will dissappear at 
the same time. If there is fever, and later, a hepatitis with 
swelling and pain on pressure, the angiocholitis is due to infec- 
tion. The symptoms are those of acute septic infection asso- 
ciated with jaundice and clay-colored stools. 

Contraction of the duct may produce the symptoms of bili- 
ary obstruction. The diagnosis rests upon the history of a pre- 
ceding angiocholitis, the former giving no pathognomonic 
symptoms. 

Growths cannot be positively diagnosed unless they can 
be felt. Cancer gives the distinctive symptoms of such neo- 
plasms, pain, and tenderness, the presence of a growth, rapid 
emaciation, progressive weakness, cachexia, and the involve- 
ment of neighboring tissues and lymph glands. Aneurysm of 
the aorta, hepatic or mesenteric arteries usually give distinctive 
symptoms. These conditions are, however, very rare in the 
aged and still rarer is occlusion produced by fibrous hands of 
adhesion resulting from peritonitis. They produce complete 
and rapid occlusion with profound systemic disturbance for 
the relief of which surgical interference is generally necessary. 
Fecal impaction is rarely massive enough to occlude the gall- 
ducts, . and when it does occur it is usually relieved in a few 
days. Obstruction due to gall-stones or concretions is usually 
accompanied by the symptoms of gall-stones. These are par- 
oxysmal pain and cramps with jaundice and intestinal distur- 
bance due to deficiency of bile. In some cases it may be neces- 
sary to make the diagnosis by exclusion. 

Symptoms. — The symptoms of biliary obstruction depend 
in part upon the location, and in part upon the degree of occlu- 
sion. The most prominent symptoms are jaundice and clay- 
colored stools, but if the cystic duct is occluded, both may be 
absent. The obstruction may be in the hepatic, cystic or 
common duct. If in the hepatic duct we must exclude gall- 
stones. If in the cystic duct the bile may flow from the Hver 
through the hepatic and common ducts to the duodenum, 
thereby preventing retention of bile with the consequent jaun- 
dice and clay-colored stools. In such case the gall-bladder is 
unable to discharge its contents and these may cause inflam- 
mation or dilatation, or else calcareous or atrophic degeneration. 
Dilatation is rare in the aged as there is generally atrophy 



BILIARY OBSTRUCTION 33 1 

of the mucous membrane and of the glands. If the glands 
are still active, the gall-bladder may become distended with 
mucus and bile, and where the abdominal walls are thin, the 
viscus can be felt as a pouch below and to the right of the 
sternum. Inflammation occurs occasionally, and almost always 
as a result of infection. A simple catarrhal cholecystitis may 
occur through extension of an angiocholitis, or from an irrita- 
tion produced by the gall-stones contained in the gall-bladder, 
especially may this happen after rough manipulation of the 
distended organ. The only symptom pointing to catarrhal 
cholecystitis is pain and tenderness over the region of the 
gall-bladder. In infectious cholecystitis there are, in addition, 
the constitutional symptoms of septic infection, chills, fever, 
nausea, vomiting, distention of the abdomen, etc. In these 
cases surgical measures are required to determine the exact 
condition and to relieve the distended organ. In most cases 
of obstruction of the cystic duct, the gall-bladder undergoes 
calcareous and atrophic degeneration, the contained gall-stones 
becoming encapsulated. If the hepatic duct is obstructed, 
jaundice and light-colored stools appear and the liver becomes 
congested but the gall-bladder is not affected. If the obstruc- 
tion is in the common duct, however, the gall-bladder becomes 
distended with bile that had been dammed back from the 
point of obstruction. Clay-colored or light-colored stools con- 
taining imdigested fat indicate a diminution in the bile supply 
to the intestines. If this occurs without jaundice the fault 
lies in the liver, which is not elaborating sufficient bile, while 
a fairly dark stool with jaundice points to obstruction of 
some of the bile ducts in the liver. The stools in biliary ob- 
struction are pasty and foul smelling. Sometimes there is 
constipation then again diarrhea as soon as intestinal decom- 
position causes irritation of the bowel. 

The most important symptom of biliary obstruction is 
jaundice. The toxemic jaundice is readily differentiated by 
the presence of an acute infection, or of arsenic or phosphorus 
poisoning, in these cases the j aim dice is not severe, the stools 
are bile-stained and the accompanying symptoms of obstruc- 
tive jaundice, pruritus, sweating and bradycardia are not 
marked. Indeed, they may be absent. 

The jaundice due to obstruction of some of the bile ducts 



332 PATHOLOGICAL OLD AGE 

in the liver may be mistaken for the jaundice of an infec- 
tious disease, as the stools are bile-stained and all the other 
symptoms are mild, but there are no symptoms of the infectious 
disease and bile pigment can be found in the urine. Jaundice 
may occur in chronic hepatitis, cirrhosis, cancer and other 
pathological states of the liver, but it is a late symptom of 
these diseases. 

Treatment. — The treatment of biliary obstruction depends 
upon the cause. The treatment for cholelithiasis is given else- 
where. In catarrhal angiocholitis the alkaline mineral waters 
should be used, and sodium salicylate may be given in 5 -grain 
doses combined with i dram of sodium phosphate every four 
hours. In all cases, whatever the cause may be, sodium choleate 
should be given in 3 -grain doses after each meal. Potassium 
bicarbonate will increase the fluidity of the bile. Calomel in 
i/io-grain doses every two hours will increase the activity of 
the liver, but in most cases the fault does not lie in this organ, 
therefore, hepatic stimulants are contraindicated. The attend- 
ing symptoms, especially the often distressing pruritus, can be 
temporarily relieved by washing the body with a i-per cent, 
solution of cocaine. In some cases a 2 -per cent, solution of 
carbolic acid in oil will help, in others hot water or cold water 
will relieve the itching. 

CHRONIC INTERSTITIAL NEPHRITIS 

Chronic interstitial nephritis is the most frequent of the renal 
affections found in the aged. It is, however, not as frequent as 
the reports of pathologists would indicate, for pathologists 
still call the normal senile contracted kidney interstitial nephri- 
tis, and physicians still diagnose every persistent albuminuria 
as Bright 's disease, especially if there are concomitant nervous 
symptoms. Walsh has pointed out that there is a physiological 
increase of connective-tissue growth between the apices of the 
pyramids going on from birth throughout life. This hyper- 
plasia is most marked in old age when arteriosclerotic nutri- 
tional changes cause atrophy of other renal tissue. Faulty no- 
menclature is partly responsible for the confusion in diagnosis, 
since several distinct conditions are included under this term 
while the same condition has received several names. Chronic 




Kidney Showing Advanced Chronic Interstitial 
Nephritis. (Natural size.) A. Ureter. B. Small 
cyst just under capsule. The irregularly lobulated, 
coarsely and finely granular surface is well shown. 
(From Coplin's "Manual of Pathology.") 






^".r" 



' * 






h-.-A' 




\.--^u''- 










Kidney, chronic interstitial nephritis. (From Coplin's "Manual of Pathology.") 



CHRONIC INTERSTITIAL NEPHRITIS 333 

interstitial nephritis, renal cirrhosis, sclerosis of the kidney, 
granular kidney, gouty kidney, contracted kidney, atrophic 
kidney, are all names used for this disease, while the same term 
is also applied to (i) a secondary condition follomng parenchy- 
matous nephritis called also small white kidney, (2) to a primary 
pathological degenerative process, and (3) to the normal senile 
degeneration, generally due to renal arteriosclerosis. The last 
of these is the normal senile contracted kidney, the ''rein senile" 
of the French. The term chronic interstitial nephritis is here 
applied to signify a primary pathological degeneration, or per- 
version of the normal degeneration and not to the secondary 
involvement of interstitial tissue following parenchymatous 
nephritis. 

Etiology. — The usual cause of chronic interstitial nephritis 
in the aged is excessive work imposed upon the physiological 
contracted kidney. The senile kidney cannot eliminate waste 
material as rapidly nor as actively as before and it is forced to 
increased activity whenever such material is produced in excess 
— as in excessive ingestion of food, especially of meat — or when- 
ever waste is retained in excess, as in constipation, and when 
abnormal material must be eliminated such as lead, iodine, 
mercury, or the products of imperfect metabolism, etc. Any 
cause responsible for an increase in any of the normal con- 
stituents, or for the production of abnormal ingredients in the 
urine, is also the cause of excessive activity or irritation of the 
kidney and consequent degeneration. We, therefore, find it 
after prolonged physical or mental labors, indiscretions in food 
or drink, in gout, chronic rheumatism, diabetes and other con- 
ditions due to impaired or perverted metabolism. The toxins 
of infectious diseases cause a parenchymatous, rarely an inter- 
stitial degeneration although the latter may follow as a second- 
ary affection through extension of the degeneration. 

Pathology. — The kidney of interstitial nephritis resembles 
the normal contracted kidney in being small, rough, dense, 
dark red in color, granular and having a closely adherent cap- 
sule. There is an atrophy of the cortex, while the region of the 
pyramids exhibits a hyperplasia of connective tissue. The 
difference between the normal senile kidney and the kidney of 
interstitial nephritis is readily seen under the microscope. In 
the latter condition there are found hyaline and fatty degenera- 



334 PATHOLOGICAL OLD AGE 

tion and cloudy swelling of the tufts, capillary vessels, and 
between the loops, the tubules are filled with casts and granular 
matter and some of the smaller vessels and glomeruli are de- 
stroyed. These degenerative changes are not found in the 
normal senile contracted kidney. 

Symptoms. — It is impossible to distinguish between the 
early symptoms of chronic interstitial nephritis and the normal 
senile kidney. A more or less persistent trace of albumin is 
present in both and the early nervous and visceral symptoms 
may be due to the senile degeneration of the organs. The 
diagnosis must be made by carefully examining the urine. In 
nephritis the quantity is increased and the specific gravity is 
lower than normal. We must remember that the normal 
output in the aged is from looo to 1200 c.c. in the male and 
from 900 to 1000 c.c. in the female and what would be normal 
in maturity is a polyuria in old age. The specific gravity in 
interstitial nephritis is sometimes as low as i.oi or even less. 
The finding of a single hyaline, fatty or granular cast determines 
the diagnosis and this will be confirmed by other symptoms. 
The patient must get up at night to empty the bladder. The 
aged usually get up once or twice a night for this purpose if 
they have a dilatation of the bladder but if one gets up several 
times at night it points to nephritis. Cardiac hypertrophy 
and high blood pressure are constant attendants. A per- 
sistent high blood pressure without arteriosclerosis is almost 
pathognomonic of this disease. Edema of the ankles may 
occur but this is rarely extensive until the heart is seriously 
involved. In many cases there are intermittent severe head- 
aches, sometimes hemicrania, often insomnia and restlessness- 
Dyspnea and asthmatic attacks may occur. Later gastric symp- 
toms, anorexia, indigestion and irregular bowel action are 
noticed. The skin becomes dry and there may be pruritus or 
eczema. Nervous symptoms appear later, such as tinnitus, 
disorders of sight, muscle twitching, cramps, etc. Diffuse 
retinitis and retinal hemorrhages, which occur frequently in 
younger individuals, are infrequent in the aged. The uremic 
convulsions which generally appear toward the termination of 
this disease in earlier life occur rarely in the old, the patient 
usually succumbing to an intercurrent disease, such as pneu- 
monia, pulmonary edema or heart disease. 



CHRONIC INTERSTITIAL NEPHRITIS 335 

Diagnosis. — It is important to differentiate between the 
senile contracted kidney and the kidney of chronic interstitial 
nephritis. In the normal senile kidney the amount of iirine is 
diminished, the specific gravity is but slightly if at all lowered, 
the urates are but slightly decreased and there are no casts. 
If there are cardiac, nervous or other symptoms, each symp- 
tom must be traced to its source and cause. If there is frequent 
urination at night we must look for a dilated bladder and en- 
larged prostate. High blood pressure may be due to arterio- 
sclerosis. The headache, gastric disorders, and nervous symp- 
toms must be considered one by one and their cause determined. 

The gouty kidney, which gives symptoms of interstitial 
nephritis, can be diagnosed by other symptoms of gout. The 
secondary contracted kidney or small white kidney follows 
chronic parenchymatous nephritis which gives pronounced 
symptoms. It must be remembered that in all cases of neph- 
ritis the diagnosis depends primarily upon the urinary analysis, 
other symptoms being merely corroborative. If after repeated 
examination no casts appear at any time we can exclude neph- 
ritis. The primary interstitial nephritis has few casts, these are 
chiefly hyaline, and has but a scanty sediment. Other forms 
of nephritis have numerous casts and an abundant sediment. 
In both the primary and secondary interstitial nephritis the 
quantity of urine is increased but the specific gravity of the 
latter is but slightly reduced, while in the former it is very low. 
The presence of albumin does not necessarily imply nephritis, 
nor does its absence exclude this disease. It is always present 
in abundance in the parenchymatous form and it is present in 
small quantities in the secondary interstitial form. It may, 
however, be absent for some time in the primary form while a 
trace may persist in the normal senile kidney. 

Treatment. — Degenerated tissue cannot be restored. The 
most we can hope to do is to avoid everything that causes 
or hastens the degeneration and to relieve symptoms or sec- 
ondary conditions by drug medications. Where the causative 
condition is controllable we can sometimes expect an improve- 
ment in the condition of the kidneys, as may be seen in the 
gouty kidney under the treatment for gout. The general treat- 
ment of the senile kidney is hygienic and dietetic. The 
dietetic regtilation is the most important and often the most 



336 PATHOLOGICAL OLD AGE 

difficult factor in the treatment of senile cases. The patient 
should have a varied diet including all the food elements re- 
quired for nutrition and in sufficient quantity to maintain 
normal weight. From this diet he must exclude as far as 
possible those substances that give the kidney excessive work, 
and those that^ would cause indigestion or constipation. The 
most important substances to be excluded or diminished in 
quantity are proteids, salt, alcohol and an excessive amount of 
fluid. Meat should be taken sparingly and omitted for several 
days at a time. The least harmful are the light meats, chicken, 
game and bacon. Broths are as injurious as meats. Vegetables 
except legumes, cereals and other farinaceous foods, fruits, 
fish and shell fish are admissible. Coffee and tea should be 
used sparingly but milk and buttermilk may be taken freely. 
The amount of salt should be diminished but a salt-free diet is 
inadvisable unless there is edema, an infrequent contingency 
in the aged. Alcohol should be forbidden unless the patient 
is accustomed to it, when the quantity should be gradually 
reduced. Alkaline mineral waters free from sodium chloride, 
preferably the natural lithia waters, are serviceable to prevent 
the formation of fibrinous plugs in the tubules. The hygienic 
regulations are a strict enforcement of the ordinary rules of 
health as applied to the invalid. Mental and physical fatigue 
should be avoided. Strong emotions and prolonged worry 
are detrimental, while mild pleasurable mental and physical 
stimuli are beneficial. Moderate exercise, stopping short of 
fatigue, should be taken, and warm baths are beneficial. 

Drug medication is indicated as soon as distressing symp- 
toms arise or whenever there is danger of grave complications, 
or for the treatment of the latter. For anorexia the simple 
bitters or orexin can be used. The bowels must be kept open 
and for this purpose aloin combined with the bile salts is in- 
dicated. The bile salts aid in preventing intestinal decomposi- 
tion. Iron is frequently recommended in this disease, but in 
the aged where there is high arterial tension it is contraindicated. 
'When the blood pressure is very high and there is danger of 
cerebral anemia or venous stasis the nitrites must be employed, 
using preferably, the i-per cent, spirit of glonoin in i -minim 
doses every three hours until the face becomes flushed and re- 
mains flushed for a few minutes. It should then be discontinued. 



RENAL CALCULUS 337 

Diuretics are rarely indicated unless the degeneration involves 
the parenchyma and the amount of urine is markedly dimin- 
ished. This, however, rarely happens. When diuretics be- 
come necessary, renal irritants, including the essential oils and 
oleoresins, should be avoided. In such case the sodium or 
potassium nitrate should be employed. In senile cases we must 
bear in mind not only the condition of the kidneys but the 
condition of the whole degenerate organism. 

UROLITHIASIS 

Renal and vesical calculi are frequent, the vesical calculus 
almost invariably originating as a renal concretion. The two 
forms of urolithiasis will be described separately. 

Renal Calculus 

Renal calculi occur frequently, sometimes without giving 
any symptoms of their presence. When minutely small they 
pass away with the urine unnoticed, forming an insoluble sedi- 
ment ; when larger they produce a local irritation in the ureters, 
bladder and urethra and pass away as gravel, or coarser sedi- 
ment. Still larger concretions pass through the ureters with 
difficulty and produce the painful symptom-complex of renal 
colic. If too large to pass through the ureter the renal calculus 
becomes impacted or imbedded in the pelvis of the kidney. 
The concretion generally consists of uric acid, sometimes of 
urates or phosphates, occasionally of calcium or carbonate 
oxalate, cystin, xanthin, fibrin, etc. The experiments of Eb- 
stein and Nicolaier have shown that the structure of the renal 
calculus is an albuminous framework filled with calcareous 
material, deposited either in concentric layers, scales or threads, 
or else as irregular crystals. The growth of the calculus keeps 
pace with the growth of the framework. The nucleus of the 
stone may be a microscopic crystal, pus, blood, pigment, fat, 
fibrin, cystin, tube cast or other urinary constituent, microor- 
ganisms or parasitic ovum. The framework is derived from an 
inflammatory process in the kidney, the calcareous material 
from the urine. 

Etiology. — Two etiological factors are necessary for the pro- 
duction of renal calculi; one which will cause the production of 



338 PATHOLOGICAL OLD AGE 

the framework, the other which will cause a change in the 
character of the urine. Anything which will produce an irrita- 
tion of the kidney will cause a mild catarrhal inflammation 
with secretion of mucus from which the framework material 
is obtained. A highly acid urine or any other renal irritant 
may do this. The most frequent change in the character of 
the urine is an excess of urea or uric acid, and we find, conse- 
quently, that uric acid calculi occur in the aged more frequently 
in connection with gout. Drinking excessive quantities of 
earthy mineral waters predisposes to phosphatic calculi. The 
derivation of the ammonium-magnesium phosphate in phos- 
phatic renal calculi is not clear, as the ammonia element is pro- 
duced in the decomposition of urine and such decomposition 
in the kidneys is generally due to bacterial infection. When 
this occurs pyelitis usually results, yet calculi of triple phos- 
phates have been found in the kidney without any other kidney 
involvement. 

Symptoms. — In some cases there are no symptoms to indi- 
cate the presence of a renal calculus. In most cases, if the 
calculus remains in the kidney, there is a dull ache in the lumbar 
region, with occasional pains shooting downward and forward 
toward the bladder, or down to the thighs. The pain is aggra- 
vated by anything that would disturb the position of the stone, 
as jolting, horseback riding, jumping, etc. This is occasionally 
followed by hematuria and pyuria. Septic symptoms may 
arise. Small calculi generally pass from the kidney to the 
bladder, producing during their passage through the ureter the 
symptoms of renal colic. There is a sudden intense pain extend- 
ing from the kidney to the testicles or labia, especially severe 
at the point where the stone is momentarily lodged in the ureter. 
There is at the same time a sharp pain at the end of the penis, 
and the testicle on the affected side is retracted. There is 
also a constant desire to urinate, but only a few drops are passed 
at a time, and the urine is then generally blood-stained. The 
usual concomitants of shock are present, namely, intense pain, 
an anxious, pale, pinched countenance, covered with cold per- 
spiration, nausea and vomiting, small pulse, slight elevation of 
temperature and collapse. The symptoms abate as soon as 
the calculus has entered the bladder, the time of passage vary- 
ing, generally from one hour to a day. The aching pain across 



RENAL CALCULUS 339 

the back may continue for two or three days, but is gradually 
diminishing in severity. Immediately after the passage of the 
stone into the bladder there is a copious flow of urine which may 
contain albumin, casts and blood. Occasionally a calculus 
becomes impacted in some part of the ureter. In such case the 
colicky pains \\'ill persist for days with a gradually diminishing 
intensity. A hydronephrosis follows, but if the other kidney 
is healthy this will give no symptoms until the excessive work 
imposed upon the healthy kidney causes its degeneration. 
Pyonephrosis and pyelitis may follow septic infection. 

The urine is acid if there is a uric acid calculus and alkaline 
if there is a phosphatic or oxalic concretion. 

Treatment. — A stone impacted in a in-eter or so situated 
in the kidney as to interfere with the discharge of the urine, 
thereby producing much distress, or causing inflammation, 
must be removed by stirgical means. If there is but distress 
without inflammation and no interference with the excretion of 
urine, medicinal measures may first be tried. The best drug 
for dissolving uric acid calculi is piperazine. This should 
be given with alkaline waters, acetate or citrate of potash, 
citrate of lithia, benzoate of soda or any other alkaline salt 
which ^t11 render the urine alkaline. If the urine is alkaline, 
pointing to phosphatic stone, the first indication is to render it 
acid by benzoic, boracic, or the mineral acids. Theoretically 
this should dissolve the stones. Prolonged acid medication has 
been followed by renal colic. It would appear that the acid 
diminishes the size of the calculus and enables it to pass through 
the ureter. 

In the vast majority of cases medical aid is first sought when 
renal colic appears. The only medical aid possible is to relieve 
the pain by hypodermics of morphine or inhalations of chloro- 
form. Hot applications to the abdomen and warm baths may 
give momentary relief, but unless the calculus is small and 
passes readily and rapidly through the ureters, the narcotics 
are indispensable. Morphine can be given in 1/4-grain doses 
combined with i/ioo grain of atropine. Hematuria is rarely 
severe enough to require treatment. If pytnia is present it 
must be treated as due to pyelitis. When surgical intervention 
is necessary the character of the operation must be left to the 
surgeon. 



340 PATHOLOGICAL OLD AGE 

Vesical Calculus • 

Vesical calculus occurs more frequently in old age than in 
earlier life and mostly in men who have a hypertrophied pros- 
tate. Many cases originate as a renal calculus which has 
passed into the bladder, either as gravel without colic, or as a 
larger concretion. The bladder being generally dilated in the 
aged, the base forms a pouch behind the enlarged prostate and 
the gravel, or stone, drops into this pouch and forms the nucleus 
for the vesical stone. The structure is the same as in renal 
calculus, mucus supplying the albuminous material for the 
framework and the decomposing urine furnishing the ammonia 
which combines with the earthy phosphates, the latter being 
precipitated in alkaline urine. The nucleus, if coming from the 
kidney, is usually a small uric acid calculus; when originating 
in the bladder, it may be any constituent of the urine which is 
liable to be precipitated in an insoluble form, or else it is epithe- 
lial debris, fibrin, cystin, etc. It has been suggested that micro- 
organisms are responsible for vesical and renal calculi but these 
appear to cause only urinary decomposition with production 
of ammonia. The production of calculi is simply the result of 
chemical and mechanical processes and of a pathological separa- 
tion of albuminous matter from the mucus which forms the 
framework of the stone. 

Symptoms. — The passage of a renal calculus with the attend- 
ing renal colic and the certainty that the stone had not passed 
through the urethra is conclusive evidence of the presence of a 
calculus in the bladder. A calculus which produces colic when 
passing through the ureter will also cause intense pain when 
passing through the urethra. The symptoms of vesical calculus 
in the aged when the stone is lodged at the base of the bladder 
behind a hypertrophied prostate, are often so vague that a 
positive diagnosis cannot be made without instrumental 
examination or radiography. The pathognomonic symptom 
of vesical calculus in earlier life, a sudden blocking of the 
urethra while urinating, does not appear when the stone lies 
behind the prostate. In most cases there is a dull ache in the 
perineum, aggravated by jolting, long marches or any motion 
which would disturb the stone. Prolonged sitting which ag- 
gravates the ache of an enlarged prostate has no such effect 



VESICAL CALCULUS 34I 

Upon a vesical calculus. Hematuria may be present and this 
symptom will simulate acute cystitis. In the latter disease 
there are vesical and rectal tenesmus and frequent urination, 
the urine is mixed with mucus, pus, and epithelium, all of which 
are mild or absent in vesical calculus. The stone can sometimes 
be felt by the finger through the rectum, its hard consistency 
distinguishing it from growths and a hypertrophied prostate. 
Vesical exploration by means of a metallic sound and of a cysto- 
scope gives the most certain information but in hypertrophied 
prostate it is sometimes difficult to so manipulate the instru- 
ments as to bring the portion of the bladder situated behind 
the prostate within view or touch. In rare cases the stone may 
be imbedded in one of the vesical pouches and the pain will then 
be located over the location of the stone. In such case the 
stone will produce a chronic cystitis but unless it is dislodged by 
a jolt a positive diagnosis can be made only by instrumental 
exploration or X-ray. When the sound and cystoscope fail to 
reveal the presence of a stone and there is any difficulty in 
reaching all parts of the viscus, a radiograph is necessary to 
clear up the. diagnosis. This course is better than to place 
the patient under an anesthetic and subject him to rough ex- 
ploratory instrumental manipulation. 

Treatment. — Internal medication, except for the relief of 
symptoms and the prevention of urinary decomposition, is use- 
less. Injection into the bladder of a very weak solution of di- 
lute hydrochloric or nitric acid has been advocated, but a weak 
solution has no effect upon phosphatic stone, while a stronger 
solution will produce an acute cystitis. We must remember 
that, while the nucleus may be a uric acid concretion from the 
kidney, the vesical deposit almost always consists of phosphates 
and the uric acid solvents are ineffectual. The only radical 
treatment is surgical, the preferable operation being lithotrity. 
In many cases where an operation for removal of stone is neces- 
sary, a hypertrophied prostate can be removed at the same 
time. When a condition exists making it advisable to perform 
a prostatectomy at the same time, the preferable operation is 
the suprapubic cystotomy advocated by Lilienthal. This 
should be performed under local anesthesia. 

In the ordinary chronic cystitis the primary cause, if per- 
sistent, must be removed. If this cannot be done, measures 



342 PATHOLOGICAL OLD AGE 

to correct decomposition of the urine and irritability of the 
bladder must be employed and continued. After the turbidity 
has cleared up salol should be used in small doses, i grain two 
or three times a day, to prevent its return. Irrigation is useful 
where there is pus or persistent mucus in the urine. If pus is 
present the silver salts are preferable but if there is only mucus, 
sodium borate and sodium sulphite should be used in the propor- 
tion of I dram to 4 ounces of warm water once daily. Hot 
applications over the bladder and hot enemata will usually 
relieve the pain which is rarely severe unless there is iilceration. 
Hyoscyamus in 5 -minim doses of the fluid extract is probably 
the most eft'ective drug to relieve pain and irritability in these 
cases. 

Acute cystitis is infrequent in the aged, except as a mild 
infection occasioned b}^ the introduction of a dirty catheter or 
a non-sterile irrigating liquid, while a mild irritation may be 
produced by some irritating abnormal ingredient of the urine. 
In either case it soon becomes chronic. An active acute inflam- 
mation is extremely rare and does not differ from the same 
disease in maturity. 

SENILE METRORRHAGIA 

Metrorrhagia is a symptom of various uterine disorders. 
Occurring during the menopause it is usually the menstrual 
flow coming on at irregular intervals. It may, however, be 
due to an endometritis, prolapsed uterus or to a growth. 
Endometritis and prolapse give clearty defined symptoms 
and the metrorrhagia accompamnng these conditions is readily 
controlled b}^ styptics. Metrorrhagia due to fibroids, polyps 
or cancer is more persistent and continues after the completion 
of the menopause. In the case of fibroids the flow usually di- 
minishes as the senile involution of the organ proceeds and it 
may cease completely. Potyps usually have a copious flow 
coming on in spurts or there ma}^ be a continous dribble. It 
generally diminishes during the menopause and may cease 
altogether. The flow that accompanies malignant disease 
begins as an insigniflcant watery, scanty discharge having a 
pinkish tinge and sHght or no odor. This discharge may 
exist for months before any attention is paid to it. It gradually 



SENILE METRORRHAGIA 343 

becomes darker and more copious and begins to have a fetid 
odor, which increases in intensity until it becomes intolerable. 
When this condition is reached the only question of diagnosis is 
between cancer and senile metritis (see Senile Metritis). In 
the early stage the effect of local treatment will usually suffice 
to distinguish the metrorrhagia of malignant disease from 
other forms of metrorrhagia. The discharge due to malignant 
disease will persist in spite of the use of styptics and astringents, 
their action lasting but a few minutes or hours. In other forms 
of metrorrhagia the flow is controlled temporarily and often 
permanently under local treatment. 

A metrorrhagia beginning after the completion of the meno- 
pause is almost invariably due to malignant disease. Other 
causes are the hemorrhagic form of senile metritis, cardiac dis- 
ease and traumatism, but these are extremely rare. The metror- 
rhagia in malignant disease sometimes begins as a scanty, thin, 
yellowish discharge, slowly becoming pinkish then darker until 
it is dark red or, if mixed with pus, a dirty red. At the same 
time it becomes thicker, more copious and continuous and 
assumes a fetid odor. In some of these cases the discharge is 
yellowish or grayish and contains drops or streaks of blood. In 
other cases the discharge is slight for a time, suddenly becoming 
copious or appearing abundantly for a few hours then dimin- 
ishing again, these gushes coming on at irregular intervals. 
It is hardly necessary here to give the other symptoms and signs 
of uterine cancer. The pain, sensitiveness on pressure, enlarge- 
ment of the organ and general cachexia, all point to malignant 
disease, but the diagnosis must be confirmed by an examina- 
tion of a curette scraping. 

The treatment of senile metrorrhagia depends upon its cause. 
If it is simply an irregular menstrual flow nothing need be done, 
but absolute rest may be necessary. Astringent solutions will 
generally avail in the case of endometritis and prolapse. These, 
and ergot internally in 1/2-dram doses, will generally tempor- 
arily control the loss of blood from fibroids and polyps ; surgical 
intervention, however, may be necessary to remove the cause. 
In all cases where there is an exhausting loss, hot douches 
should be given and if these do not suffice to control the flow 
astringents like tannic acid, perchloride of iron or zinc sulphate 
should be added. As a last resort packing of the uterus may 



344 PATHOLOGICAL OLD AGE 

be tried but occasions for this are extremely rare. The most 
effective means to destroy the fetor of cancerous discharges is a 
douche containing a tablespoonful of a 3 -per cent, solution of 
permanganate of potash to a pint of water. Hot douches have 
no effect in controlling hemorrhage in uterine cancer. If hemor- 
rhage occurs, powerful astringents, such as Monsell's solution 
diluted I to 8, or the sulphate of iron and ammonium in lo-per 
cent, solution, will be required. The effect is, however, only tem- 
porary and the cure will depend upon the cure of the causative 
condition. ' 



CHRONIC RHEUMATISM 

This is a primary disease of middle and advanced age which, 
in its pathology, resembles the changes of senile arthrosclerosis. 

Etiology. — In some cases there is a history of earlier attacks 
of acute articular or subacute rheumatism, but only in rare 
instances has either of these diseases immediately preceded 
chronic rheumatism. The basic etiological factor is unknown, 
but it occurs most frequently in those who are much exposed to 
cold and dampness and who are generally weakened by im- 
proper living and hard work. The disease is probably but a 
perversion of the ordinary senile processes in the joints brought 
on earlier than usual through some local causes. 

Pathology. — The most marked anatomical changes are 
found in the articular cartilages which become roughened; and 
in the ligaments and tendons, which become thickened and 
hardened. The synovial membrane also thickens and the syno- 
vial fluid is usually diminished in quantity. The muscles atro- 
phy from disuse and there are often evidences of senile changes 
in other tissues. 

Symptoms. — The disease is slowly progressive with occa- 
sional acute exacerbations and often with long periods of remis- 
sion. It begins as a dull ache in the affected joints, generally 
in the evening after the joints have been actively used during 
the day. They feel stiff and sore and may be swollen. The 
stiffness persists throughout the night and is relieved after 
slight active motion in the morning. Slowly and gradually the 
stiffness increases until finally the joint is completely and per- 
manently anchylosed. It may take many years after the initial 



CHRONIC RHEUMATISM 345 

symptoms appear before the final result is reached. Exacer- 
bations wdth increased stiffness, pain and swelling, which lasts 
for several days, will occasionally occur. The joints most fre- 
quently affected are those most frequently used or exposed to 
deleterious influences, i.e., the hands of manual laborers and 
the feet of those who walk much. In many cases one hand or 
one foot alone or a hand and a foot on the same side are af- 
fected. The large joints are seldom involved. The disease is 
frequently associated with senile changes in other tissues and 
these contribute their symptoms to the symptoms of the 
disease. 

Diagnosis. — In the early stage of the disease it must be 
differentiated from the early stage of arthritis deformans and 
from senile arthrosclerosis. In multiple arthritis deformans a 
number of joints are affected and the disease is bilateral, os- 
teophytes appear and the flexors are contracted. It is impos- 
vSible to distinguish between chronic rheumatism and arthri- 
tis deformans in an early stage when only a single large joint 
is involved. Later, the presence or absence of flexion and 
deformity will determine the diagnosis. It is also important 
to differentiate between chronic rheumatism and arthrosclerosis 
and this can be determined by a single symptom. The pain and 
stiffness of the joint in chronic rheumatism are relieved after 
limbering up in the morning, while in arthrosclerosis there is 
no pain during rest and motion produces more and more pain. 
In gout a single joint is affected and there are paroxysmal 
attacks coming on at night. In gonorrheal rheumatism there 
is the history, the symptoms are more active and the disease 
is rare in the aged. Progressive muscular atrophy has been 
mistaken for chronic rheumatism, but in that disease there is 
little or no pain. The difficulty of motion in these cases is 
due to waste of muscle and not to joint stiffness, the apparent 
enlargement of the joints being due to the retraction of the 
wasted muscles. 

Treatment. — Permanent arrest of the disease has followed a 
complete change in the mode of life of the patient with avoid- 
ance of exposure to cold and wet and residence in a dry warm 
climate. The iodides are sometimes beneflcial, but more lasting 
results have followed hydrotherapy, electrotherapy and ther- 
motherapy. In some cases hot applications, in others cold 



346 PATHOLOGICAL OLD AGE 

applications seem to do better. The ''baking" process has 
been followed by permanent relief and cures have been reported 
from the use of the high-frequency current. Massage and 
vibration frequently relieve the stiffness and have been found 
of temporary benefit even after complete anchylosis. General 
tonics must be employed and for this purpose nothing equals 
phosphorus and arsenic. 

ARTHRITIS DEFORMANS 

This disease, often erroneously called chronic rheumatism, 
is a primary progressive disease of the joints occiming during 
or after middle life. 

Etiology. — The basic cause is uncertain. Two general 
theories are held, (i) that it is of nervous origin and (2) that it 
is a bacterial disease. Poncet claims it to be a tubercular affec- 
tion of the joints, and Valentine found that 40 per cent, of cases 
of arthritis deformans had tuberculosis. The bacterial theory 
is based upon the fact that microorganisms have been found 
in the joints of cases that began mth acute symptoms. As 
the disease is usually insidious in its advent, it is probable 
that, where cases begin with acute symptoms, those symptoms 
belong to an acute infectious disease, perhaps to acute articular 
rheumatism, with which the arthritis deformans has nothing in 
common except the one single symptom of pain in the joints. 
The neurotic theory is based upon (i) the similarity of the 
lesions to some spinal-cord lesions, (2) the frequent occurrence 
of dystrophies, (3) the influence of mental disturbances and 
emotions in its causation. Each of these can be controverted 
by the simple fact that they do not apply to the majority of 
cases. Damsch offers a toxin theory. Ord advances a theory 
that the disease is due to a lesion in the trophic centers of the 
cord. A further study of this disease, however, shows that 
the anatomical changes are identical with the normal senile 
joint changes, but they proceed faster and are carried further 
than in senile arthrosclerosis. The disease begins in the joints 
that have been most actively employed, generally the hands, 
followed by the ankles and feet, then the knees, wrists, elbows, 
shoulders, cervical spine, hips and lastly the dorsal spine. 
The flexor muscles, which are the ones that are the most 



ARTHRITIS DEFORMANS 347 

actively employed, become permanently contracted, thereby 
producing the deformities which are pathognomonic of this 
disease. From these facts it would seem that the disease is 
but an early and exaggerated senile process. The pains are 
due to degeneration of the nerve terminals in the affected 
tissues. 

The exciting causes are unknown. Every conceivable 
departure from a natural mode of life — the excessive use of 
amylaceous and saccharine food, exposure, exhaustion, sexual 
excesses, unhygienic surroundings, rapid temperature changes, 
etc., have been cited as possible exciting causes. 

Pathology. — The articular cartilages become dry, fibril- 
lated and wear away through attrition, leaving the bone exposed. 
The spongy portion of the bone wastes, the articular surfaces 
roughen and eburnation ensues as the result of friction. Osseous 
nodules, or a complete osseous ring may form about the articu- 
lating surface. The synovial membrane thickens and the sac 
becomes dry. Thickening and hardening of the ligaments and 
tendons and waste of the muscles contribute to the anatomical 
changes which cause the characteristic deformities marking the 
disease. 

Symptoms. — The disease appears in three forms, complete 
or multiple, partial, and abortive. 

The multiple form is the most frequent, and usually begins 
as a dull ache in a single joint of a finger or toe which later 
becomes swollen and painful to the touch or upon motion, 
while the joint becomes flexed. In the meantime the corre- 
sponding joint on the other side becomes affected. The affec- 
tion spreads to other joints of the hand or foot and to the corre- 
sponding joints on the opposite side. The effusion is slight, 
never as extensive as in acute articular rheumatism, nor is the 
pain in the early stage of the disease severe. There may, 
however, be neuralgic pains, or the more persistent pains of 
neuritis, due to irritation or degeneration of the nerve ter- 
minals in the affected tissues. The disease is progressive, with 
frequent remissions, the relapses being generally more severe 
than the previous attacks and increasing the deformities. In 
an advanced stage of the disease the fingers turn toward the 
ulnar side, are flexed and may overlap. The wrists turn out- 
ward, the elbows are bent, the shotilders are fixed, with the 



348 PATHOLOGICAL OLD AGE 

arms hanging down and the hips and knees are flexed. The 
amount of rigidity in different joints may vary, but the corre- 
sponding joints of the two sides are generally affected to the 
same extent. 

Complete anchylosis is rare, true bony anchylosis occurring 
only in the spinal column. A famous example of complete 
rigidity of the joints was "the ossified man," who was on public 
exhibition for many years. Various skin disorders occasion- 
ally appear in connection with the disease. There may be 
pigmentation, bromidrosis, or local sweating, paresthesias, etc. 

The acute form of rheumatic arthritis, which begins with 
symptoms resembling an acute articular rheumatism, does not 
occur in old age. 

The partial form, also called the monarticular type is con- 
fined principally to one, or a few of the larger joints, while the 
smaller joints either escape entirely, or are but slightly affected. 
There is the same train of symptoms, beginning with tenderness, 
then effusion and pain with remissions and exacerbations, 
gradual stiffening of the joint, and deformity. 

Morbus coxcB senilis is a form of partial arthritis deformans 
in which one hip, or, rarely, both hips are affected. The 
capsular ligament and ligamentum teres contract and other 
joint changes take place. The leg is apparently shortened and 
gradually becomes fixed in a bent position. 

Spondylitis deformans is a rheumatic arthritis confined to 
the spinal column. It occasionally terminates in complete 
bony anchylosis. The abortive form of arthritis deformans 
usually begins in the distal joints of the fingers but rarely passes 
beyond them, though it may affect the toes. It is marked by 
the production of exostoses, called ''Heberden's Nodes," rang- 
ing in size from a pin's head to a pea, which form on the sides 
and ends of the distal joints of the fingers. The changes in the 
joints are the same as in other types, but there is rarely a con- 
traction of the flexor tendons or waste of muscle. In some 
cases the presence of the nodes is the only symptom.. 

Diagnosis. — In the early stage of arthritis deformans it is 
often difficult to distinguish it from other arthritic diseases. 
The acute form of the multiple type resembles, in its onset, acute 
or subacute articular rheumatism, but this form does not occur 
in the aged. The slow insidious advent, the absence of fever, 




Heberden's nodes. (Courtesy of S. Epstein, M. D., New York.) 



f'i 



.i 




Spondylitis Deformans. Regular Contour. X-ray shows ossification of in- 
ter vertebral articulations. (Courtesy of S. Epstein, M. D., New York.) 




Spondylitis Deformans. 



Irregular Contour. Sidevaew. 
M. D., New York.) 



"(Courtesy of S. Epstein, 



ARTHRITIS DEFORMANS 349 

the involvement of the small joints, and the stationary character 
of the anatomical changes in the beginning of the disease mil 
distinguish it from subacute rheumatism. Crepitation upon 
motion which is appreciable to a delicate touch, is often an early 
symptom of rheumatic arthritis. This is absent in subacute 
and chronic rheumatism. Chronic rheumatism is generally 
unilateral, and the affected joints are usually stiff and painful 
after prolonged rest. The stiffness and pain are diminished 
after motion, whereas motion increases the pain of rheumatic 
arthritis, resembling, in this respect, senile arthrosclerosis. 

Gout attacks a single joint; generally of the big toe, the 
attack is paroxysmal, comes on at night and is much more severe 
than the attack of rheumatic arthritis. 

Other arthritic diseases can be eliminated by the age, his- 
tory, or by pathognomonic symptoms. 

Treatment. — The disease is progressive, but the attacks of 
swelling and pain become gradually less frequent and less 
painful, while the rigidity proceeds until the patient is bed- 
ridden. The disease is incurable and, while temporary relief 
can be afforded during the acute exacerbations, no method of 
treatment has given permanent results. Drug treatment is 
useless except to relieve pain, when the salicylates or opiates 
may be given. Of the non-medicinal measures, hydrotherapy, 
electrotherapy, mechanotherapy and thermotherapy have been 
employed in various forms, some cases being temporarily relieved 
by one form of treatment, while in other cases the progress was 
apparently hastened. The most that can be expected from 
them is a prolonged remission with temporary lessened rigidity 
of the joints. In one case treatment at the hot sulphur springs 
at Aix la Bains was followed by a remission lasting two years. 
Hot baths and fomentations give temporary relief. The high- 
frequency current has been found beneficial in some cases and 
reports of apparent ciire have followed the use of the X-ray with 
massage. Favorable reports have come from the hot-air treat- 
ment and Bier's hyperemia treatment. 

Temporary relief from the deformity of the hands was 
obtained in one instance by immersing them in hot water for 
half an hour, then forcibly extending the fingers. The fingers 
remained extended for several days and motion was possible, 
but they soon began to resume their flexed position. 



350 PATHOLOGICAL OLD AGE 

Of hygienic measiires, mild exercise and the prevention 
of mental depression caused by the ill success of treatment are the 
most important. Gentle exercise is necessary, but fatigue 
should be avoided. Active exercise of the affected joint hastens 
the pathological changes, while no exercise will cause waste of 
muscle from non-use. Of psychic measures, change of sur- 
roundings and scene is the most important. The benefits 
derived from a trip to a watering place, or to medicinal springs 
are attributable, in great meastire, to the change of surroundings, 
for the same mineral waters taken at home do not produce the 
same results. Other hygienic measures, such as a dry equable 
climate, the avoidance of surface chilling, nutritious dieting, 
etc., are self understood. 

PAGET'S DISEASE 

Etiology. — This rare disease of the bones occurs almost 
exclusively in advanced age. It consists of an increase in the 
volume of bone as seen in acromegaly and a softening of bone 
as in osteomalacia and it is supposed that the same causes 
producing these conditions, namely, disease of the hypophysis 
and of the thyroid, are responsible for the trophic changes in 
Paget's disease also. Numerous other causes, such as fatigue, 
exposure to cold or wet, traumatism, syphilis, cancer, etc., 
have been suggested. Some observers found spinal lesions in 
their cases, others failed to find any, but arteriosclerosis of the 
vessels supplying the affected bones is found in almost every 
case. 

Pathology. — The anatomical changes in Paget's disease 
consist of waste of bone tissue in some places and hyperplasia 
in others. The Haversian canals in some localities are enlarged, 
in others, obliterated. There is no uniformity in location, 
degree or extent of these changes and all the bones may be 
affected, but the most pronounced changes are found in the 
tibi^ and femurs. Owing to the softening of these bones and 
to the downward pressure of the body upon them, they become 
curved and the neck and shaft of the femur form a right angle. 
The marrow is very vascular and the periosteum is thickened. 

Symptoms. — The onset of the disease is insidious, often 
unnoticed until a change in the shape of the bone is observed. 



i 




Paget's Disease. Nouvelle Iconographie de 
la Salpetriere, May-June, 1905. 




Paget's Disease Radiogram of lower jaw showing waste of bony structure. (Courtesy 
of S. Epstein, New York.) 



GOUT 351 

In some cases there are vague pains and aches as in chronic 
rheumatism, occasionally there are paroxysmal sharp pains 
in the affected bones. Pain is sometimes present throughout 
the disease, in some cases aggravated upon walking, in some 
cases coming on in paroxysms, in other cases absent. When 
the spinal column is pressed upon, as may occur in the deformity 
that accompanies spinal osteitis deformans, or when a nerve 
is compressed the pain becomes increasingly severe. The most 
important symptoms are thickening and malformation of the 
bones, the character and extent of deformity depending upon 
the location of the affected bones and the amount of pressure 
to which they are subjected. For this reason the spine and 
lovrer extremities are most deformed, the increased curvature 
of the spine producing a change in the shape of the thorax. 

The only disease which bears any marked resemblance to 
Paget's disease is osteomalacia, which is very rare in the aged. 
In osteomalacia all the bones of the body are affected, the 
curvature of the spine is very marked and the pelvis is deformed, 
while in Paget's disease the deformity is usually confined to the 
lower extremities. Pain is usually pronounced in osteomalacia 
and generally absent in Paget's disease. The bones are not 
increased in size in osteomalacia. Acromegaly is extremely 
rare after the sixtieth year and it does not affect the extremities. 

The disease is incurable but it may last for ten or fifteen 
years before an intercurrent disease, generally bronchopneu- 
monia, causes death. 

There is no known method of treatment and the only 
thing that can be done is to treat the distressing symptoms. 
Phosphorus has been found of benefit in osteomalacia and it 
may reHeve symptoms of Paget's disease, but no cure has yet 
been effected. 

(Pseudo-Paget's disease is included under the first group.) 

GOUT 

Gout is a clinical syndrome arising from defective assimi- 
lation of nitrogenized substances."^ 

Numerous theories have been advanced to explain the patho- 
genesis and nature of gout but no one is free from unanswerable 

^Rathery, "Manuel des Maladies de la Nutrition." 



352 PATHOLOGICAL OLD AGE 






criticism. Biurate of soda is deposited in the joints, but th^ 
origin of the uric acid is uncertain, some investigators beheving 
it to be a product of incomplete metabolism, some think it al 
product of perverted metabolism, while others say it is the 
product of complete metabolism of purin-forming substances. 
Garrod's theory that uric acid is retained in the blood instead of 
being eliminated by the kidneys has now few supporters. He 
placed the primary fault into the kidneys. Another theory ex- 
plains gout as due to a hyperproduction of uric acid, a minute 
quantity being normal to the individual. Ord ascribes the source 
of this hyperproduction to the products of degeneration of certain 
fibrous tissue; Murchison claims it to be a functional perversion 
of the liver whereby albuminoid material is converted into uric 
acid instead of into urea; Ebstein believes that the sources of 
normal production of uric acid are multiplied in gout. Another 
theory is that uric acid and the purins are not completely con- 
verted or destroyed owing to deficiency of deoxidizing ferments 
(oxydases) in the blood. Other theories ascribe the presence of 
an excessive amount of uric acid in the circulation to the changed 
condition of the blood, a uric-acid dyscrasia, the diminished 
alkalinity causing incomplete oxidation; others claim that in- 
creased alkalinity makes the blood a poorer solvent, therefore, 
a larger quantity of uric acid is thrown from its solution and de- 
posited in the tissues, again that the tissues in which the biurate 
of soda is deposited are less alkaline than the blood, some think 
that where the circulation is slowest the salt is deposited, and 
finally, that certain tissues have an affinity for this salt. Other 
theories are based upon the chemical changes by which the 
biurate of soda is produced; that uric acid and thyminic acid 
are formed together from the nucleins and are in combination 
and that in gout more uric acid is formed; or that uric acid is 
derived from substances that do not form the thyminic acid, 
or that uric acid is precipitated as an insoluble biurate in the 
presence of glycocoll, or that the urates exist in two forms, a 
stable and but slightly soluble one and an instable and readily 
soluble one, that the latter is converted into the former, etc. ; 
The latest theory is that uric acid is produced in excess from ; 
certain proteids containing purin-forming bases and that it is the ^ 
end result of the metabolism of such purins. Another theory 
which has many supporters ascribes gout to a faulty metabolism 



GOUT 353 

of proteids through failure of the nervous system to properly 
regulate the process of metabolism. 

These are but few of the many theories that have been ad- 
vanced to explain the pathogenesis and nature of gout. There 
are arguments which cannot be controverted in some cases, 
while in other cases they are completely refuted. 

Etiology. — In most cases there is an inherited gouty diathesis. 
In some there is another disorder of metabolism such as obesity, 
diabetes, etc., giving symptoms of gout in addition to its own 
symptcmxs and the disappearance of the other disorder relieves 
the symptoms of gout. 

It is most frequently found in those using fermented liquors 
and in coimtries where wines, heavy beers and ales are consumed 
in large quantities. Its frequency among those who drink such 
liquors, and its rarity among drinkers of distilled liquors would 
seem to point to a fermentation product and not to the alcohol 
as the etiological factor in these cases. This would also explain 
the increase of the disease in America, keeping pace with the in- 
crease in the consumption of beer. It is probable that its fre- 
quency among lead workers, type founders, painters, etc., is 
due to the large quantities of beer and ale consumed by them 
to quench the intolerable thirst of chronic plumbism. In many 
cases of chronic lead, zinc or mercury poisoning or where opium, 
belladonna, iodides or nitrites have been used, there is more or 
less suppression of the secretions, with consequent excessive 
thirst, which is often quenched by alcohoHc, or, more especially, 
fermented Hquors. This will account for the frequent attacks 
of gout in such conditions. It may be, too, that these toxins 
interfere with metabohsm and if combined with a gouty diathesis 
an attack will be produced. 

Rich, highly seasoned food in an excessive amount is an eti- 
ological factor, such food being also rich in purin-forming mate- 
rial. Gout, however, often attacks those who are insufficiently 
nourished and the so-called poor man's gout does not differ 
from the gout of those who live idle lives, eat rich food and drink 
heavy wines. While excesses in food and drink, especially of 
nitrogenized foods and fermented liquors, are the principal eti- 
ological factors, yet any mental strain, sudden emotion, infectious 
disease, tratimatism, excessive venery, or fault in the mode of life 
may bring on an attack in a person having the gouty diathesis. 
23 



354 PATHOLOGICAL OLD AGE 

Pathology. — The pathognomonic lesion is a deposit of bi- 
urate of soda in the affected joints. This begins just below the 
free surface of the articular cartilage and the deposit gradually 
increases, invading the joint structure and incrusting the carti- 
lage with a layer of sodium biurate. Later the tendons become 
involved and a salt deposit is found upon them and sometimes 
upon the synovial membrane. The synovial fluid becomes 
thickened and may contain crystals of the salt. The salt fre- 
quently collects in small masses, called tophi, which surround 
the joint and may appear on the tendons a short distance from 
the joints. Tophi are also frequently found in the cartilage of 
the ear, occasionally in the cartilages of the nose and other 
cartilaginous structures, but rarely in muscle. 

During an acute attack, the affected joint is inflamed. In 
most cases the disease begins in the first joint of the big toe, 
later involving the ankles, knees and lastly the joints of the fingers. 
Occasionally the fingers are first affected. The kidneys are 
sometimes involved, showing either the changes of nephritis or 
bitirate of soda deposits. 

Varieties. — Many forms and varieties of gout have been 
described, all can be placed under two heads, however, i.e., 
regular and irregular gout, the latter usually called goutiness. 
Gout is a chronic condition, every case being chronic from its 
inception, and the term chronic gout in contradistinction to other 
forms of gout is a misnomer. The paroxysmal attacks called 
acute gout are incidents occurring in the course of the chronic 
disease, and cannot be considered an entity apart from the 
chronic condition any more than could the symptom-complex 
known as cardiac asthma, occurring after exertion in cardiac 
dilatation, be called a separate disease. Gout rarely begins with 
an acute attack. Premonitory symptoms showing the existence 
of a gouty condition usually appear days, weeks or months before 
the acute attack and there is almost always some discoverable 
cause for it. What is usually described as acute gout will be 
treated here as an acute attack of regular gout. Irregular or 
extra-articular gout, or goutiness, is applied to a number of ill- 
defined pathological lesions or functional perversions found in 
persons having a gouty diathesis. With the increase of gouti- 
ness there is an increasing tendency to ascribe to it any patho- 
logical condition for which no other etiological factor can be 



GOUT 355 

discovered. This variety of gout presents an acute phase, the 
retrocedent gout which immediately follows the acute attack of 
regular gout. 

Symptoms. — In some cases of regular gout there are no 
marked symptoms until the onset of the acute attack, in other 
cases there are prodromal symptoms appearing a few days 
before the attack, while in some there are various functional 
impairments with occasional twinges in the small joints for 
weeks or months before an attack occurs. Between the at- 
tacks, the patient may feel in perfect health, or there may be 
functional impairments (which will be described under Irregular 
Gout) or twinges in the affected joints. Usually the patient 
does not notice the prodromal symptoms of the first attack, 
headache, loss of appetite, malaise and little aches and twinges 
in the small joints of the toes, and occasionally of the hands. 
Having once experienced an attack, however, he will quickly 
notice these premonitory signs and there will be restlessness 
and depression brought on by the anticipation and fear of the 
attack. The onset is ushered in with an intense pain coming 
on suddenly or rapidly and generally at night, and in most 
cases involving the big toe. The joint becomes red, swollen, 
intensely painful, and tender to the touch, and there are the 
usual concomitants of fever, rapid pulse, dry skin, thirst, head- 
ache, mental excitement and general malaise. The symptoms 
abate somewhat during the day, becoming worse at night. 
After the third or fourth day the symptoms become gradually 
milder and the arthritic inflammation disappears in about ten 
days. 

The urine during an attack is scanty and strongly acid, 
depositing urates upon standing. The amount of uric acid 
eliminated during the attack varies ; occasionally none is found, 
at other times it may be present in excess. After the attack, 
the quantity of urine is increased and its specific gravity is 
diminished but it remains hyperacid and there is a large excess 
of uric acid for several days. 

The acute attack of regular gout is often followed by an 
acute attack of irregular or retrocedent gout. 

After several attacks, tophi form in the joints and in other 
places, the attacks becoming less frequent and in the aged less 
severe. 



356 PATHOLOGICAL OLD AGE 

The protean character of irregular gout makes a general 
description of this condition impossible. Disorders of the 
circulatory, respiratory, nervous, digestive and urinary systems, 
of the skin, bones, joints, and organs of special sense, have all 
been attributed to goutiness, and often improperly. The only 
variety about which there can be no question is retrocedent gout. 
Immediately following an acute attack of regular gout, there 
sometimes occur acute symptoms of gastric, intestinal, cardiac 
or nervous disorders. They come on suddenly and may subside 
as suddenly without treatment. The gastric symptoms are 
those of cardialgia or of acute gastritis ; the intestinal symptoms 
resemble colic with constipation or diarrhea. The cardiac symp- 
toms are those of a mild angina. The nervous symptoms 
simulate apoplexy or aphasia, or there may be mental aberration. 

There is no one pathognomonic symptom of goutiness and 
the diagnosis must often be made by the family history in the 
absence of other etiological factors. The diagnosis of the 
pathological lesion itself may not be difficult, but it is often 
important to determine the etiological factor before instituting 
treatment. The affections most frequently associated with the 
gouty diathesis are catarrhs, neuralgias, muscle cramps, and a 
form of nephritis called gouty kidney, which presents as its 
principal symptom occasional uric acid ''showers," and deposits 
of gravel in the urine. Burning and itching of the feet may be 
due to the gouty diathesis and the chronic eczema of the aged is 
frequently associated with goutiness. Glaucoma, iritis, keratitis, 
etc. , have been attributed to it. Other diseases, like emphysema, 
asthma, aneurysms, cardiac inefficiency, thrombosis, hemor- 
rhoids and hepatic congestion, have been ascribed to' it. Simi- 
larly there have been described gouty pharyngitis, gouty cir- 
rhosis, arthritic colics, gouty phlebitis, gouty myalgia, gouty 
kidney, etc. Of these the gouty kidney alone gives clear 
symptoms, pointing to the underlying condition. These are 
an intermittent albuminuria which may be cyclic, and occasional 
showers of uric acid, an excess of phosphates or crystals of cal- 
cium oxalate. 

In many cases of visceral disease the only point in favor of 
a diagnosis of goutiness is a family history of gout with absence 
of any other etiological factors. If the disease comes on sud- 
denly, and especially if the urine shows an excess of uric acid, 



GOUT 357 

the diagnosis is strengthened. But even where we are certain 
that the gouty diathesis exists we must consider all other 
etiological factors that may produce the condition present and 
eliminate them before we can make a positive diagnosis of irregu- 
lar gout. 

Treatment. — In most cases of regular gout the physician is 
first called during an acute attack and then simply for the relief 
of pain. Colchicum and its preparations have stood the test 
of time and these are our only trustworthy remedies. But 
the indiscriminate use of this drug in every case of gout and at 
every stage betrays an inexcusable ignorance of its action. 
Colchicum is only of service during an acute attack and such 
attacks are infrequent in the aged. It is, moreover, a powerful 
cardiac depressant and gastric irritant and is cumulative in 
its effects. The dose is 1 5 minims of the tincture or wine every 
four hours until the pain is relieved when its use should be 
stopped. Though usually prescribed in combination with 
potassium iodide the latter drug has no effect upon the attack, 
neither shortening nor ameliorating it. 

If an acute attack does occur in the aged it is safer to give 
1/2 -milligram dose of colchicine, repeated if necessary in four 
hours, but no more for another twenty-four hours. The urine 
should be made alkaline by the persistent use of potassium bicar- 
bonate and a daily evacuation of the bowels should be secured. 
For local treatment the application of hot water followed by a 
cocaine ointment or liniment wiU afford temporary relief. The 
pain may be of such severity that it becomes necessary to 
resort to narcotics. In that case we can give morphine combined 
with or following a minute dose of atropia. The salicylates 
and iodoform in grain doses have been given with apparent 
benefit in some cases. The treatment in the intervals, i.e., 
between the acute attacks, is mainly hygienic and dietetic. 
Remarkable results have been obtained at some of the European 
spring resorts but (as stated in connection with diabetes) 
it is probable that the benefit derived is due more to the strict 
regimen than to the effect of the waters, for the same waters 
taken at home do not produce the same effect, while cases of 
gout occur even among inhabitants of these resorts who do not 
follow hygienic and dietetic rules. The principal resorts for 
gouty patients are Carlsbad, Franzensbad, Marienbad and 



35^ PATHOLOGICAL OLD AGE 

Teplitz, all in Bohemia. The hygienic measures are a dry- 
climate, frequent warm bathing, warm clothing to guard against 
sudden changes of temperature, mild active exercise and a 
strict regulation of diet. Lime salts and sodium salts, especially 
common table salt, should be avoided as far as possible. Malt 
liquors, wines, cider and all fermentation products are to be 
prohibited. If alcoholic drinks are required we can allow 
whiskey but no gin. Light meats may be taken but dark meats, 
liver, kidneys, sweetbreads and other glandular meats are 
injiuious. A vegetable diet is best, but fried dishes, pastries, 
pies, sweets or candies, and an excessive amount of farinaceous 
food, tomatoes, rhubarb, and sweet potatoes do harm. 

There is no specific treatment for irregular gout. The 
pathological conditions in the viscera must be treated and the 
hygienic and dietetic measures given must be adhered to. 
Among drugs, there is none giving uniform results. Piperazine 
hastens the elimination of uric acid, and, in some cases, a pro- 
longed course of piperazine water seems to ward off acute attacks; 
in other cases it is worthless. The same applies to the alkaline 
treatment with citrate of potash or lithia. The iodides have no 
effect in this disease. Phosphoric acid has apparently given 
good results in some cases, but in others it seemed to have had 
an opposite effect. Diet and hygiene are our only reliable 
measures. 



DL^ETES MELLITUS 

Diabetes mellitus is a clinical syndrome, the most important 
symptom of which is a glycosuria, which arises from a defect in 
the assimilation of carbohydrates, sugar then being found in 
the blood and tissues which is eliminated by the urine in quan- 
tities far exceeding the normal amount. 

Glycosuria itself is not pathognomonic of diabetes for it may 
be produced experimentally by the ingestion of large quantities 
of sugar. In this case there is no perversion of metabolism, 
but simply an inability of the normal metabolic processes to 
completely convert an excessive quantity of sugar at one time. 
After the excess has been eliminated the urine becomes normal. 
If the milk glands are removed shortly before or after parturition 
there is a temporary glycosuria, the process by which glycogen 



DIABETES MELLITUS 359 

is converted into galactose and milk sugar being halted, and 
grape sugar, an intermediate product, is then formed. This 
grape sugar is eliminated by the urine. Glycosuria may also 
occur during or after diseases of the liver, brain, the ductless 
glands, infectious fevers, pregnancy and after ingestion of poi- 
sons. In some of these cases the glycosuria may persist long 
after the cause has passed away. Some authorities declare 
that this form of glycosuria being due to a perversion of carbo- 
hydrate metabohsm should also be called diabetes mellitus, 
others will not apply the term diabetes to this temporary 
glycosuria, as it disappears normally, but apply this term to a 
more or less permanent glycosuria which in its milder form can 
be controlled by diminishing the intake of carbohydrates. 
Still others insist that there is not diabetes mellitus unless the 
attending symptoms of polyuria, polydipsia, bulimia and ema- 
ciation are present. Since neither the nature nor the patho- 
genesis of diabetes is known, the term will here be applied to 
any glycosinia that is due to perversion of the metabolism of 
carbohydrates, whether primary or secondary, temporary or 
permanent. It should not be applied to simple transitory 
glycosuria arising from an excessive ingestion of sugar, nor to 
the glycosuria following amputation of the breast. 

Some authors claim that there are many forms of diabetes 
mellitus depending upon the gravity, stage, probable etiological 
factor, complications, etc. Diabetes, however, really appears 
in but two forms, the temporary, self -limited form which is 
secondary to the diseases just mentioned, and the more or less 
permanent one, which is really the true diabetes melhtus. 

True diabetes mellitus may present its accompanying symp- 
toms in a marked degree or may appear with symptoms so mild 
as to be imnoticed. In some cases a progressive loss in weight 
first attracts the attention of the patient, in other cases there 
may be a vague feeling of malaise without any clearly defined 
symptoms and an examination of the urine is necessary to clear 
up the diagnosis. 

Notwithstanding an enormous amount of research work 
in metabolism, the processes by which carbohydrates are con- 
verted into glycogen and from glycogen into the various sugars 
and fats, is still undetermined. 

It is believed that glycolitic agents, in the nature of ferments, 



360 PATHOLOGICAL OLD AGE 

exist in the pancreas, kidneys, lungs, white blood corpuscles, 
etc., and that these ferments cause the transformation of glyco- 
gen into sugar. A deficiency or a perversion of the functions of 
these ferments interferes with the complete combustion of the 
sugar and it is retained in the blood to be eliminated by the urine. 
An injection into a dog of diabetic urine, from which the sugar 
had been removed, will produce glycosuria, and the same result 
follows if the intestinal contents of a diabetic person are injected 
into the intestine of a dog. A glycosinia is also produced in 
animals by the injection of adrenal extract. In these cases 
legions of the pancreas are found, evidently due to the action 
of the adrenalin upon the pancreatic cells of the islands of 
Langerhans. The adrenals do not themselves affect carbo- 
hydrate metabolism. It is their overstimulation that causes 
the production of excessive secretion which interferes with the 
nutrition of the pancreatic cells, the function of these cells being, 
probably, the secretion of the glycolitic ferment. In about 
50 per cent, of diabetic cases these cells are found in a state of 
hyaline or granular degeneration, or in a state similar to that 
found in other organs undergoing senile involution, i.e.y atrophy 
and sclerosis. The blood in the aged has the tendency to hold 
the products of incomplete and perverted metabolism, also the 
products of intestinal decomposition and other toxic matter; 
likewise an excess of lime salts and waste material, and these 
abnormal substances do not produce the same constitutional 
disturbances that appear in younger individuals. For this 
reason diseases due to disturbed metabolism like gout, diabetes, 
chronic rheumatism, and some infectious diseases like erysipelas 
and diphtheria appear in a mild and exceedingly chronic form. 
As diabetes in the aged is almost always associated with 
arteriosclerosis, there may be an etiological factor common to 
both, or the arteriosclerosis may produce malnutrition with 
consequent degeneration of the cells furnishing the glycolitic 
ferment. 

Many theories have been advanced to explain the production 
and conversion of sugar, and the causes for the impairment 
of the chemical processes involved. Since many of the theories 
apply to some cases or hold good under some circumstances 
and fail in others, it is evident that there are several causes 
and various processes that can produce the same end result. 



DIABETES MELLITUS 36 1 

It would serve to no purpose to enumerate these theories or 
dilate upon the elaborate chemical formula used to explain 
carbohydrate metabolism. Magnus Levy has pointed out 
sources of error in theories based upon animal experimentation. 
In these experiments a rapid, radical and serious damage is 
done to the organism. In human diabetes the decrease of 
sugar utilization goes on slowly and progressively and the 
organism partly adapts itself to the new conditions. Moreover, 
the dog (most frequently used in these experiments) is a car- 
nivorous animal, and there is some difference in the metabolism 
of carbohydrates. This may account for the rarity of acidosis 
in canine diabetes. 

While in about one-half of all cases lesions of the pancreas 
are present and in most other cases lesions of the liver or of the 
nervous system are foimd, there are some cases presenting no 
lesion whatever and apparently there is no etiological factor to 
account for the disease, while in other cases lesions are found 
but it is impossible to determine any relation between them and 
the disease. Extirpation of the pancreas is followed by diabetes, 
but the disease may be present T^dth a healthy pancreas. Extir- 
pation of the thyroid in the dog was followed, in over 60 per cent, 
of experiments, by diabetes yet diabetes is found complicated 
by or associated with Basedow's disease. 

This much is certain: there are numerous factors which 
can disturb carbohydrate metabolism, and this disturbance 
may occur anywhere between the intestines, i.e., the point of 
ingress into the circulation, and the kidneys, the point of egress. 
It may result from some lesion in one of the organs producing 
the glycolitic agent, or it may occur without such lesion, as a 
result of functional disturbance in cells engaged in the process 
of metabolism. The sugar is derived from the carbohydrates 
taken into the system, but it may also be derived from the 
proteins, Kulz ha\ang found that in a diabetic kept on an exclu- 
sive protein diet, increase in this diet increased the sugar output, 
while Pfiuger found that the sugar may come from the proteins 
of the body. It is possible that some sugar is derived from the 
glycerine of fat. -^^ 

Etiology. — Statistics show a constantly increasing proportion 
of diabetics in civilized countries. This may be ascribed to 
increased mental and nervous strain with decreasing physical 



362 PATHOLOGICAL OLD AGE 

exercise and to changes in the mode of life brought about by 
the introduction of new methods of preparing food, and of food 
that is too rich. 

Heredity seems to have some influence as an etiological 
factor, but it is a question whether such influence is really 
inherent or is simply the result of similar environment and mode 
of life. The relative frequency of diabetes among Jews is prob- 
ably due to the fact that they are mostly engaged in sedentary or 
non-active occupations and their mode of life favors mental 
and nervous strain. The disease occurs occasionally in families 
having a gouty diathesis or a disposition to obesity, but while 
some see therein an argument in favor of heredity, it is probably 
simply coincidence. Diet is an uncertain etiological factor, 
some authorities claiming that a vegetarian diet predisposes 
to diabetes, others showing the comparative rarity of diabetes 
among peasants who live almost exclusively on a vegetable diet. 
Diabetes does not occur more frequently among sugar and candy 
workers than among others and while the consumption of sugar 
is far greater among females, diabetes occurs in only one-third 
as many females as males. It is found frequently, however, 
among obese beer drinkers. In cases where the disease is 
traceable to faulty alimentation, either in carbohydrate excess 
or disproportion, there is probably a dyscrasia or predisposition 
to this disease. 

It is often impossible to determine what the exciting cause is. 
The disease sometimes follows a shock or fright, more often there 
has been a long period of worry or mental strain. It occasion- 
ally follows cerebral traumatism. Many cases follow acute 
general infectious diseases, and it has been found after local 
infections. In by far the largest number of cases, however, 
there is a disease of the pancreas or liver. In other cases there is 
a nervous or mental defect, a neurosis or psychosis preceding or 
accompanying the diabetes. Since we do not know the patho- 
genesis of' the disease, we frequently assume a causal relation 
without any other basis than absence of other etiological factors. 
The temporary glycosuria of secondary diabetes may produce a 
permanent diabetes. 

Pathology. — In some cases no pathological lesion or condition 
can be found, except an excess of sugar in the blood, the proportion 
being as high as i to 2 50 instead of i to 1000 or less. Fat granules 



DIABETES MELLITUS 363 

may appear in the blood plasma. The most frequent patholog- 
ical condition is a degeneration of the cells of the islands of 
Langerhans in the pancreas. There is occasionally a pancreatitis 
or a degeneration in some other part of the organ. The liver is 
often hypertrophied, but in senile cases it is generally atrophied 
and sclerotic. In the rare bronzed diabetes in which the viscera 
and skin are pigmented there is a pigmentary hypertrophic 
cirrhosis of the liver, the pigmentation of the other organs being 
probably secondary to the change in the liver. In the kidneys 
there is frequent evidence of nephritis. Various other kidney 
lesions have been noted, but these may have been incidental 
complications. The same can be said of other lesions occasion- 
ally found in diabetic cases, as some are undoubtedly secondary 
to arteriosclerosis. 

Sjrmptoms. — The disease is usually well advanced before 
any symptoms pointing to it make their appearance. In one 
case the patient did not notice any loss in weight or strength, or 
excessive thirst until two years after a glycosuria was accident- 
ally discovered. In the temporary diabetes following an infectious 
or other disease the patient makes a slow recovery and does not 
regain strength and weight as fast as he should in normal con- 
valescence. The appetite improves, but there is no correspond- 
ing gain in weight, and there is a polydipsia, though it is not as 
marked as in the permanent form of diabetes. The urine is 
slightly, if at all, increased in amount, but it contains from 1/2 
to 2 per cent, of sugar. A diminution in the intake of carbo- 
hydrates will diminish the quantity of sugar; however, it is 
rarely necessary to resort to an exclusive protein diet to get a 
sugar-free urine. By simply limiting the ingestion of carbo- 
hydrates in these cases the glycosuria will disappear. 

In the permanent diabetes the earliest symptom is usually a 
loss in strength, often ascribed to ageing. The patient notices 
that, in spite of a good appetite, he loses in weight, and it is for 
this loss in weight that he seeks medical advice. Close question- 
ing may then bring out the additional symptoms thirst and poly- 
uria. Ageing patients do not pay attention to these symptoms 
until they become severe, but will readily notice loss in weight 
and strength and, ascribing these to age, they become depressed. 
When the disease is well advanced the mouth becomes dry and 
the tongue red, glazed and furrowed. The urine is greatly 



364 PATHOLOGICAL OLD AGE 

increased in quantity necessitating frequent micturition. The 
appetite increases until there is a constant desire for food even 
after the patient had just finished a hearty meal. This bulimia 
is greatly aggravated as soon as the carbohydrates are reduced 
in the course of treatment, and where wheat in the form of bread 
is withdrawn, the appetite may be insatiable. The thirst keeps 
pace with the polyuria, which in turn increases as the amoimt of 
sugar increases. When, associated with arteriosclerosis the 
symptoms of the latter disease appear in high blood pressure, 
headache and vertigo, mental and emotional depression. The 
temperature is often subnormal. Constipation is a frequent 
complication and is often associated with gastric disturbances. 
Nervous symptoms appear, especially when the disease is of 
nervous origin. There may be neuralgia, muscle pain, paralysis, 
etc. The skin becomes dry and a slight trauma, such as a scratch 
or the prick of a pin, will often become an extensive and serious 
lesion. These surface lesions rarely heal without suppuration, 
and if deep-seated, they may become gangrenous. It is prob- 
able that the frequency of furuncles, carbuncles, chronic ulcers 
and gangrene in diabetic cases is due to the increased amount 
of sugar in the blood, the blood thereby becoming a good cul- 
ture medium for the pyogenic cocci. Eczema of the genitals 
and herpes zoster are occasional complications. The most im- 
portant symptom, however, is glycosuria. The quantity of 
urine is generally dependent upon the amount of sugar, al- 
though in diabetes following cranial traumatism we may find a 
polyuria (5 to 6 liters in twenty-four hoirrs) with a sugar con- 
tent of but I 1/2 to 2 per cent. Usually, if there is over 5 per 
cent, of sugar, there will be from 4 to 5 liters of urine in twenty- 
four hours, and as the sugar percentage sinks the total quan- 
tity of urine diminishes. Cases passing as much as 28 liters 
in one day have been reported. The excretion is generally 
more voluminous at night than by day and there is often a 
retention of a few drops which pass away a few moments after 
the bladder had been apparently emptied. If dropped on the 
clothes and dried, there will be a deposit of sugar. Naunyn 
gives the following figures which show the relation between 
the amount, specific gravity and sugar percentage. 
2 liters passed in 24 hours should have a specific gravity of 1028 
to 1030 corresponding to 2 to 3 per cent, sugar. 



DIABETES MELLITUS 365 

3 liters passed in 24 hours should have a specific gravity of 1028 
to 1032 corresponding to 3 to 5 per cent, sugar. 

5 liters passed in 24 hours should have a specific gravity of 1030 

to 1035 corresponding to 5 to 7 per cent, sugar. 

6 to 10 liters passed in 24 hours should have a specific gravity of 

1030 to 1042 corresponding to 6 to 10 per cent, sugar. 

The amount of urea is generally increased and this is probably 
due to the increased ingestion of proteins and if much meat has 
been taken there may be also a considerable amount of uric acid. 

Albumin is frequently found in the urine of diabetics. In 
some cases it is a symptom of a complication, as nephritis, in 
other cases it is due to the excessive protein food introduced in 
the course of treatment, in still other cases it is apparently due 
to a faulty metabolism of proteids, which accompanies the meta- 
bolic defect in diabetes. Many theories have been advanced to 
explain the presence of this albumin, but none are satisfactory. 
Still more unsatisfactory are the theories advanced for the pres- 
ence of amino-acids and acetone bodies found in the urine of 
late cases of diabetes. Acidosis occurs only in grave cases, and 
rarely in the aged. Phosphaturia is a frequent complication. 

Normal blood contains about 1/4 part of sugar in 1000, 
which may be increased to i part or i 1/4 part immediately 
after the ingestion of a considerable amount of saccharine matter, 
but several hours later the sugar proportion has dropped to 
normal. In diabetes the sugar in the blood may be increased 
to 3 or 4 parts in 1000, but the proportion varies according to the 
ingestion of carbohydrates and gravity of the disease. The 
amount of fat in the blood is generally increased and may reach 
the proportion of 270 parts in 1000 (Frugoni). In the early part 
of the disease the blood is hydremic, but after polyuria becomes 
pronounced it is concentrated, with a specific gravity of 1030 to 
1059. The blood is sometimes lighter in color, probably due to 
the fat, as the hemoglobin content is usually normal. 

Sugar is sometimes found in the sweat, occasionally in ascites 
and other serous transudations, but rarely in the saliva. Dia- 
betic coma, which usually occurs in younger individuals at the 
closing stage of the disease, is infrequent in old age. This coma 
is probably due to the toxic effects of the acetone bodies. It 
may come on slowly or rapidly and death may follow in a few 
hours or it may be delayed for several days. The diagnosis 



366 PATHOLOGICAL OLD AGE 

of diabetes mellitus is simple, but error may occur if the patient 
is first seen during the comatose state. If the diagnosis cannot 
be determined from the history, it may be necessary to withdraw 
the urine by means of a soft catheter. If there is no sugar it is 
not diabetes. Diabetes in the aged is generally mild but ex- 
tremely persistent. Under a restricted carbohydrate diet 
patients may live for years without discomfort. Carelessness 
in diet or a sudden shock may increase the sugar output and re- 
sult in acidosis. 

Treatment. — Since we do not know what prevents the com- 
plete combustion of sugar in diabetes, the only rational method 
of treatment is to limit the ingestion of carbohydrates. The die- 
tetic treatment is still our main reliance in the control of this 
disease, supplemented by measures which have given favorable 
results in some cases. The only unalterable rule is to diminish 
the amount of the carbohydrates, but while in some cases it will 
be necessary to increase the caloric value of the food, in other 
cases, the patient will do better if the caloric value is not increased, 
but in the obese, or where the disease is far advanced, it must 
be diminished. The aged diabetic requires a diet containing 
about the same caloric value as in health, which is about 30 
calories per kilogram weight daily, or about 2000 calories at a 
weight of 145 pounds. 

It is rarely necessary, nor is it advisable, to make a sudden 
and profound change in the diet by excluding carbohydrates 
entirely, as in all early cases, and in many advanced cases too, the 
organism can tolerate a certain amount of carbohydrate food 
without the production of sugar. It is, therefore, necessary to 
determine the point of carbohydrate tolerance and this can be 
done by placing the patient upon Von Noorden's Standard Test 
Diet which is as follows: 



Von Noor den's Standard Test Diet 

Breakfast. — 200 grams coffee or tea with one or two table- 
spoonfuls of thick cream. 

100 grams of hot or cold meat (weighed after cooking). 
Two eggs, with or without bacon or corned beef. 
50 grams of white bread. 



/ 



DIABETES MELLITUS 367 



Lunch. — Two eggs cooked as desired, but without flour; 
or any other hors d'oeuvre free from flour. 

Meat (boiled or roasted), fish, venison or fowl, accord- 
ing to taste, about 200 to 250 grams altogether (weighed 
when cooked). 

Vegetables, such as spinach, cabbage, cauliflower or 
asparagus, prepared with broth, butter or other fat, eggs 
or thick sour cream, but without any flour. 

20 to 25 grams creamy cheese (such as Brie, Camem- 
bert, etc.) ; plenty of butter. 

Two glasses of light white or red wine, if desired. 
One small cup of coffee with one or two tablespoonfuls 
of thick cream. 

50 grams of white bread. 
Dinner. — Clear meat soup, with egg or green vegetable in it. 
One or two meat dishes as at lunch. 
Salad of lettuce, cucumber or tomatoes. 
Wine. 
No bread. 

Drinks during the day, exclusive of wine, one or two 
bottles of aerated water. 
The total urine excreted during the twenty-four hours is 
collected, that of the day and of the night separately, and is 
examined quantitatively for sugar. Both the percentage con- 
tents, and more especially the whole quantity of sugar excreted 
in the twenty -four hours is noted. 

If on this fare no sugar is excreted, the quantity of bread is 
gradually increased until sugar does appear in the urine. If on 
the other hand, sugar is excreted with this test diet, the patient 
is first kept on the same fare until the daily excretion of sugar has 
become nearly constant. Then the quantity of bread is grad- 
ually diminished. At each stage in the diminishing process the 
patient is kept on the same amount of bread long enough to 
allow the sugar excretion to get a constant value, proper to this 
stage. 

The largest amoimt of white bread which can be taken with- 
out causing sugar to appear in the urine is then taken as that 
particular patient's point of carbohydrate tolerance. 

These meals allow 100 grams of white bread having a 60 
per cent, starch content daily. When the point of carbohy- 



368 PATHOLOGICAL OLD AGE 

drate tolerance has been determined the amount of white 
bread can be replaced by other carbohydrates according to the 
following table of carbohydrate equivalents: 

TABLE OF EQUIVALENTS 

30 grams of white bread equal in carbohydrate contents 

Breads and Other Farinaceous Foods 

Brown bread 40 grams 

Corn bread 40 grams 

Rye bread 36 grams 

Graham bread 36 grams 

Gluten bread 36 grams 

Biscuit 32 grams 

Roll (French) 32 grams 

Roll (Vienna) 32 grams 

Crackers (Boston) 24 grams 

Crackers (Graham) 24 grams 

Crackers (Oyster) 24 grams 

Pretzel 24 grams 

Ginger bread 28 grams 

Chocolate cake 28 grams 

Sponge cake 28 grams 

Cookies (molasses) 24 grams 

Lady fingers 24 grams 

Doughnuts 32 grams 

Spaghetti 120 grams 

Macaroni 120 grams 

Vermicelli 120 grams 

Almond meal 260 grams 

Soja bean meal 200 grams 

Potato gluten biscuit 180 grams 

Pure gluten biscuit 200 grams 

Barkers gluten food, A 409 grams 

Barkers gluten food, B 296 grams 

Barkers gluten food, C 216 grams 

Vegetable gluten 68 grams 

Gum gluten 48 grams 

Glutona 32 grams 

Glutosac bread 60 grams 

Protopuff No. 1 180 grams 

Protopuff No. 2 48 grams 

Jireh whole wheat bread 48 grams 

Vegetables 

Celery 150 grams 

Radishes 450 grams 

Asparagus 550 grams 

Cabbage 310 grams. 

Cauliflower 400 grams 



DIABETES MELLITUS 369 

TABLE OF EQUIVALENTS.— {Continued) 

Cucumber 600 grams 

Lettuce 600 grams 

Mushrooms 250 grams 

Sauerkraut 450 grams 

Spinach 600 grams 

Tomatoes 450 grams 

Beets (cooked) 260 grams 

Lima beans 200 grams 

Carrots 260 grams 

Corn (canned or green) 88 grams 

Egg plant 360 grams 

Parsnips 140 grams 

Green peas 120 grams 

Potatoes 88 grams 

Sweet potatoes 30 grams 

Turnips 224 grams 

Cereals 

Barley (cooked) 27 grams 

Hominy (cooked) 100 grams 

Oatmeal (cooked) 160 grams 

Rice (cooked) 60 grams 

Farina (cooked) 100 grams 

Fruits 

Apples 180 grams 

Bananas 80 grams 

Grapes 128 grams 

Muskmelon 448 grams 

Oranges 160 grams 

Peaches 200 grams 

Pears 200 grams 

Prunes 96 grams 

Strawberries 260 grams 

Watermelon 900 grams 

Cherries 150 grams 

Blackberries 160 grams 

Cranberries 180 grams 

Currants 160 grams 

Raspberries 150 grams 

Grapefruit (weighed with skin) 750 grams 

Desserts 

Apple pie 40 grams 

Lemon pie 36 grams 

Custard pie 78 grams 

Rice pudding 56 grams 

Tapioca pudding 60 grams 

24 



370 PATHOLOGICAL OLD AGE 

TABLE OF EQUIVALENTS.— (Continued) 
Milk and Milk Products 

Pure milk 448 grams 

Cream 448 grams 

Koumyss 334 grams 

Matzoon 886 grams 

Kefir 7^0 grams 

Buttermilk 375 grams 

Condensed milk (sweetened) 33 grams 

Condensed milk (unsweetened) 144 grams 

Evaported cream 144 grams 

Beverages 

Beer (dark) 250 grams 

Beer (light) ; . . . 300 grams 

Ale 298 grams 

Porter 238 grams 

Sherry wine 510 grams 

Port wine 258 grams 

Champagnes 108 grams 

Rhine wines (red) 570 grams 

Rhine wines (white) 600 grams 

Italian wines 495 grams 

Miscellaneous 

Cocoa (unsweetened) 50 grams 

Chocolate (unsweetened) 60 grams 

Peanuts 80 grams 

If for example the point of carbohydrate tolerance is found 
when 60 grams of white bread are taken in a day, 30 grams of the 
bread can be replaced by 120 grams of spaghetti or by 100 grams 
of lima beans, 112 grams of cream and 112 grams of muskmelon. 
If bread is entirely omitted the craving for this one article of food 
becomes intolerable and the patient will either starve or violate 
orders. The ordinary gluten bread contains almost as much 
carbohydrate as the white bread and most of the so-called dia- 
betic gluten breads contain a large percentage of starch. The 
only diabetic flour containing no starch is casoid flour, which is 
a mixture of albuminoids. If this is substituted for the ordinary 
white bread a much larger quantity of other carbohydrates can 
be taken. Diabetics differ in their tolerance toward certain 
foods, the same carbohydrate equivalent of one food producing a 
glycosuria in one and not in another who has the same point of 
tolerance. Articles toward which there is an intolerance must 



DIABETES MELLITUS 37 1 

be avoided. Foods that are absorbed slowly, such as contain a 
large amount of cellulose for example, are better than those that 
are rapidly absorbed. The oatmeal cure recommended by Von 
Noorden consists of the daily administration of from 200 to 250 
grams of oatmeal, preferably in the form of gruel in divided 
doses at intervals of two hours. In addition to this, from 200 
to 300 grams of butter and 100 grams of proteid food are allowed. 
Black coffee or tea, good old wine or a little brandy is permitted. 
After three or four days of this diet the patient is placed upon a 
vegetable diet for a day or two, the vegetable content not to 
exceed the point of carbohydrate tolerance. Various theories 
have been advanced to explain the frequent success in diminish- 
ing the quantity of sugar and acetone under the oatmeal diet. 
It has been suggested that the large amount of cellulose in oat- 
meals causes very slow absorption, or that the large amount of 
water in gruel diminishes the total quantity of the oatmeal, 
again that upon a single carbohydrate diet the appetite wanes 
and less of all kinds of food is taken, or that the oatmeal is con- 
verted beyond the stage of sugar. Some of these explanations 
apply as well to other single carbohydrate diets, as for example to 
the potato cure, rice cure, etc. It is certain that the glycosuria 
is diminished whenever the diet is restricted for a few days to a 
single carbohydrate and smaller amounts of protein and fat than 
normal. If excessive sugar persists in the urine, notwithstand- 
ing the diminution of carbohydrates to the point of exclusion, the 
intake of protein must be reduced. These cases, however, are 
rare in the aged. In many instances it is possible to reduce the 
amount of sugar in the urine to i or i 1/2 per cent, without 
great restriction of carbohydrates, and only complete exclusion 
of starch and sugar from the diet will bring it down to normal. 
If the patient feels well with a glycosuria containing i or i 1/2 
per cent, of sugar and does not lose weight, the point of carbohy- 
drate tolerance should be established upon that basis. The 
indiscriminate use of fats in diabetes may lead to acidosis. 
Stern has shown that the fats containing a large proportion of 
fatty acids of a low molecular weight favor the production of 
acetone, but, if the fatty acids have a high molecular weight, 
they yield little acetone. This would exclude from the diet 
butter and cream, but not olive oil, lard or suet. He recommends 
the yolk of eggs as the most valuable fatty substance in diabetes, 



372 PATHOLOGICAL OLD AGE 

especially in acidosis. Instead of sugar, saccharine or levtdose 
can be used to sweeten coffee and tea and when these become 
distasteful glycerin may be used instead. It is impossible to 
arrange a strict diet list for the aged diabetic, because the dis- 
ease is rarely severe in them, therefore much greater leeway can 
be permitted in the matter of diet to maintain physical strength. 
An exclusive protein diet would produce gastric and intestinal 
disturbances and would so far reduce the patient's strength that 
recovery would be impossible. 

Non-dietetic measures include aerotherapy, electrotherapy, 
hydrotherapy, hygienic measures, surgical measures and drugs. 
Abrams in his work on spondylotherapy recommends concussion 
of the seventh cervical vertebral spine and reports cases where 
diabetes has been benefited by this method of treatment. It 
is well known that diabetes in hot countries is milder and more 
prolonged than in colder countries and this has led to the dry- 
heat treatment. In a dry air with a temperature of from 80 
to 90° F. the glycosuria diminishes and the symptoms of diabetes 
become milder. Upon exposure to cold the glycosuria and 
other symptoms become as pronounced as before. 

The treatment by electricity has not been satisfactory. 
DeKraft reports cures from the employment of high-frequency 
currents, Tousey thinks they may be harmful, Stern says they 
do not influence the intensity of glycosuria, azoturia or aceton- 
uria. Other observers make similar contradictory reports. 

Many cases of diabetes are apparently cured at the Bohemian 
mineral springs, especially at Carlsbad and Franzensbad. It 
is hardly possible that the waters themselves effect the cure, 
since the waters taken at home do not produce the same results. 
This was shown in the case of a man, age sixty -five, with symp- 
toms of diabetes and a sugar content of 5 per cent., who after a 
six weeks' course at Carlsbad gave a sugar content of but i 1/2 per 
cent. It rose soon after his return, however, and in two months 
it again reached 5 per cent., notwithstanding a partly restricted 
diet . The following year the same course was followed by the same 
result. The third year he took the waters at home, following, 
to a modified extent, the strict routine and diabetic regimen 
insisted upon at Carlsbad, and his sugar content dropped to 
21/2 per cent. The next year he returned to Carlsbad and 
there was again the usual result, diminished glycosuria and 



DIABETES MELLITUS 373 

relief of other symptoms. Undoubtedly the psychic influence 
of the environment and strict regimen were the most important 
factors. Free intestinal elimination is an important adjunct 
to the dietetic measures, and in some cases free catharsis with 
restricted diet may effect a cure. Any of the saline cathartics 
act equally well. 

Medicinal measures are usually required to relieve symptoms 
or to prevent complications, and sometimes they are employed 
as a general tonic. Occasionally medicinal remedies are given 
to cure the disease and there are reports of recoveries from the 
use of some drugs. In every case, however, the dietetic meas- 
ures must be included in the treatment. The use of uranium 
nitrate in 5 -grain doses will sometimes reduce the amount of 
sugar. Methylene blue, strontium lactate, chloride of gold and 
sodium, iodoform, antipyrin, mercury bichloride, and arsenic 
have all been recommended, yet they almost invariably fail to 
give the results obtained by those who advocate their use. 
Sewall reports an absence of sugar after the administration 
of an infusion of lean meat acidulated with hydrochloric acid 
and Horowitz reports a like result from the administration of 
the lactic acid bacilli. Rudisch recommends atropine sulphate 
in doses of from 1/150 grain gradually increased to 1/20 grain 
and atropine methylbromide in doses of 2/15 grain gradually 
increased to 8/15 grain, while Stern obtained only toxic effects 
from these large doses. Codeine has stood the test of years 
and is still frequently used when dietetic measures alone fail 
to reduce the quantity of urine. 

It is, however, rarely necessary to resort to other than 
dietary measures in senile cases except for the relief of distressing 
symptoms and as a prophylactic to prevent coma. When acido- 
sis appears sodium bicarbonate or potassium bicarbonate must 
be given in doses of 10 grains repeated every 4 hours. If coma 
supervenes in spite of the alkaline treatment, it almost invariably 
ends in death. A few recoveries are recorded, however, follow- 
ing the intravenous injection of soda bicarbonate, using 500 c.c. 
of a 3 per cent, solution, and giving one or two injections daily. 
Large quantities of the salt may be required and Hanssen reports 
a case in which 240 grams were given in 10.6 liters of water in 
ten half hourly doses. For the relief of thirst the valerianates, 
ammonium valerianate or quinine valerianate in 5 -grain doses, 



374 PATHOLOGICAL OLD AGE 

can be given. Water acidulated with phosphoric or citric acid 
(sweetened with glycerin) and small pieces of ice are of tempo- 
rary utility. Bulimia can be temporarily controlled by cocaine 
hydrochlorate given in i/8-grain doses. The cocaine, however, 
is a cardiac depressant, and if frequently repeated, will cause 
habituation and gastric atonicity. Food containing a large 
amount of cellulose, or requiring much chewing, as under- 
done meats, should be taken in small quantities and eaten 
slowly. 

Headache is usually due either to acidosis or arteriosclerosis 
and the treatment depends upon the cause. 

Jaundice is due either to pancreatic or hepatic disease. If 
it disappears under the administration of calomel given in 
repeated small doses, say i/io grain every two hours, or sodium 
glycocholate in 2 -grain doses twice daily, we have a diabetes of 
hepatic origin to deal with. A persistent jaundice under this 
treatment does not exclude disease of the liver, but it points 
with greater force to pancreatic diabetes. Digestive and intes- 
tinal disorders are frequent complications of diabetes, due, no 
doubt, to the changed alimentation and changed character of 
the blood, whereby the nutrition of the organs becomes impaired. 
Occasional lavage will increase the activity of the stomach and 
remove food particles that have begun to decompose. For 
constipation the most effective treatment is a pill containing 
dried ox gall 5 grains and aloin 1/4 grain, at night, followed in 
the morning by a saHne. Diarrhea indicates a catarrhal condi- 
tion of the bowel generally due, in the aged, to excessive food, 
occasionally to intestinal fermentation and irritation. In the 
latter case the stools are foul-smelling. This condition can be 
relieved by intestinal antiseptics. Fatty diarrhea and steator- 
rhea indicate involvement of the pancreas or liver or perhaps 
of both. Beside the treatment of the causative condition 
the fat ingest a must be diminished. 

Albuminuria is found in about 40 per cent, of all cases. A 
trace of albumin is generally present in the urine of the aged 
and signifies a senile contracted kidney. Unless there are 
symptoms of nephritis (casts, etc.), or when albuminuria appears 
suddenly in a large amount, it may be disregarded. 

Loss of virility is a frequent accompaniment of diabetes. 
This is probably due in most cases to the male climacteric 



DIABETES MELLITUS 375 

which occurs about the end of the fifth decade and to the natural 
loss of virility due to ageing. It has no significance apart from 
the mental depression that its discovery occasionally produces. 
Nothing should be done for it. 

Ocular and aural disorders sometimes complicate matters. 
Diabetic cataract may improve when there is an improvement 
in the general disease but other disorders require special treat- 
ment directed to the organ involved. 

Pruritus is a frequent accompaniment and occasionally it 
is the most annoying symptom. Its favorite sites are about 
the genitals and anus where it is often associated with bromidro- 
sis and intertrigo and about the legs. In moist locations the 
treatment must be directed to the hyper hi drosis. Stearate of 
zinc and salicylic acid will generally relieve the excessive secre- 
tion and, if the itching continues, inunction with a 2 per cent, 
cocaine ointment, using lard or any animal fat as a base, will 
afford temporary relief. This ointment can also be used in 
localities where the skin is excessively dry. The intensity of 
the pruritus depends upon the intensity of the glycosuria. 
The resistance of the diabetic to infectious disease, especially 
to septic infection, is considerably lowered, the opsonic index 
being approximately one- third lower than normal. It is proba- 
ble too that the sugar-laden blood is a better culture medium 
than normal blood. We find consequently streptococcus and 
staphylococcus infections (in the form of furuncles, carbuncles, 
abscess, cellulitis and septic gangrene) frequently attacking 
diabetics. Dry gangrene occurring in diabetes is not due to 
that disease but to arteriosclerosis, embolus or other cause that 
prevents nutrition of the part ; the greater tendency to infection 
may, however, convert a dry gangrene into a purulent one. 
Serum therapy in the form of a vaccine injecting the three 
varieties of the staphylococcus pyogenes, aureus, albus and 
citreus, has been found cirrative in some cases of diabetes with 
infection when used at the onset of the complicating lesion. If 
this fails, local treatment must be instituted. Furuncles 
generally, and occasionally carbuncles at their onset, can be 
aborted if a needle at a white heat is thrust into the center of 
the inflamed elevation. In more advanced cases of carbuncle, 
cauterization by lunar caustic or caustic potash, or else excision, 
is necessary. Carbuncle in the aged is a grave disease and com- 



376 PATHOLOGICAL OLD AGE 

plete excision at the earliest possible moment is in most cases the 
only method of successfully dealing with it. 

The treatment of gangrene in diabetes is purely surgical. 
The serum therapy may be tried, but unless there is rapid and 
marked improvement no time should be lost in local medication. 
The danger from operative procedure is less than the danger 
from septic gangrene, and with modern methods of anesthesia 
and surgery, operations upon diabetics are no longer prejudged 
fatal. 

CEREBRAL HYPEREMIA 

Cerebral hyperemia does not differ in the aged from the 
same condition in maturity. Passive congestion, however, is 
more frequent, being often due to the impaired jugular circula- 
tion following dilatation and tricuspid disease. 

Active hyperemia in the senile occurs after excitement, 
physical exercise, excessive food, coffee, tea or alcohol. It 
begins with a sense of heat in the head, then a ftdness and a 
beating with throbbing temples, spots before the eyes, buzzing 
in the ears, vertigo and a dulling of the intellect tending to 
unconsciousness. The face is flushed and conjunctivae are 
injected, carotids are prominent and their impulse is marked. 
The attack passes away in a few minutes if the cause is removed. 

Passive hyperemia is a chronic condition due to venous 
stasis. It may occur as a temporary condition if the cause is of a 
temporary nature, as the presstire of a tight collar, stooping, 
coughing, etc. In the permanent condition there is either a 
valvular disease which interferes with the return circulation, or 
else some local interference, such as a growth pressing upon the 
jugular. The symptoms are persistent headache, drowsiness 
with inability to sleep when lying down, vertigo, flushed face 
and marked prominence of the jugulars. The arteries, however, 
are not prominent. 

Treatment of cerebral hyperemia depends upon the form and 
the cause, which must be removed whenever possible. This 
can generally be done in active hyperemia and in those cases of 
passive hyperemia or venous stasis, the causes of which are tem- 
porary, as external presstire. In cases due to interference with 
the venous circulation, following cardiac disease, or the pressure 



11 




Tremorgraph — Paralysis agitans, left hand. (Neustaedter, Med. Record, July 17, 1909. 




Early paralysis agitans; facial as- 
pect characteristic. Attitude not yet 
pronounced. (Dr. M. Neustaedter's 
case.) 



PARALYSIS AGITANS 377 

of a tumor, we must resort to temporary measures to lessen the 
cerebral circulation. The most effective measures for this pur- 
pose are hot foot or sitz baths. Local hyperemia in other parts 
of the body may be produced by mustard, turpentine stupes, hot 
cloths, cold to the head, etc. If there is danger of apoplexy, 
leeches to the temples or cups to the chest and back, or vene- 
section must be employed. Drugs are useless. Ergot which is 
serviceable in earlier life is dangerous in the aged if there is 
cerebral arteriosclerosis. The opiates and alcohol increase the 
hyperemia and chloral is dangerous on account of its depressing 
action upon the heart. The bromides will relieve reflex irrita- 
tion and veronal can be used for the insomnia. The head must 
be kept raised and the feet lowered even in sleep. Rapid ca- 
tharsis \\dll sometimes relieve the hyperemia if due to excessive 
food or coffee or alcohol. The coal-tar preparations acetphe- 
netidin, acetanihd and similar preparations depress the heart 
and leave it depressed. 

PARALYSIS AGITANS 

Paralysis agitans is a progressive motor neurosis of middle 
and advanced age. Neither its cause nor its pathology are 
known, there is no lesion distinctive of the disease, and of the 
many theories advanced for its pathogenesis, none is satisfactory. 

Etiology. — The basic etiological factor is unknown. At the 
present moment, we ascribe the cause for anatomical and func- 
tional perversions to microorganisms or to perverted internal 
secretions. It has been suggested that paralysis agitans may be 
due to atrophy of the parathyroid glands, but it is more probably 
due to a senile change in the motor branches of the spinal nerves, 
although no change in them has been demonstrated. There is 
generally a neurotic tendency, and in many cases an etiological 
factor affecting the brain or spinal cord can be discovered. It 
may be shock, fright, intense emotion, prolonged worry or fear, 
or overwork. In some cases there is a history of traumatism, in 
others an acute infectious disease preceded the advent of the 
paralysis agitans. Exposure to cold, dampness, unhygienic 
surroimdings and poverty have been given as the exciting 
causes, while in many cases no cause can be found. 

Pathology. — The only pathological condition present in every 



378 PATHOLOGICAL OLD AGE 

case is an arteriosclerosis of branches of the spinal arteries. 
This has, however, been found in cases which did not present 
the symptoms of the disease and on the other hand far advanced 
paralysis agitans presented on autopsy but slight vascular 
changes. 

Symptoms. — Paralysis agitans presents a characteristic 
clinical picture. Though a tremor disease, there are cases with- 
out tremor, cases where the tremor is temporarily absent, but the 
attitude and gait are always present. When standing the patient 
is bent over as though he were about to fall forward, his knees 
and elbows are bent, the hands are held in the position of holding 
a pen or rolling a pill. The walk corresponds with the attitude, 
the bent position being maintained, and there is a forward pitch 
with short, rapid, shuffling steps which must be kept up until an 
obstruction is met with. In the early stage of the disease the 
patient can stop himself, but when the disease is well advanced he 
will continue to go forward until stopped or until he falls and if 
pushed or pulled backward he will continue going backward 
until stopped. The attitude is due partly to a gradually in- 
creasing rigidity of the muscles first of the neck and back, later 
of the extremities and face. As a result of this muscle stiffness, 
voluntary movements become difficult, slow and deliberate. 
This is well seen in the hand writing which, aside from the trem- 
ulousness, becomes so small and cramped as to be almost illegible. 
Owing to the rigidity of the muscles of the face it becomes ex- 
pressionless, not apathetic as in dementia, but mask-like. 

The tremor, which in most cases is the earliest and most 
pronounced symptom, usually begins as a fine trembling in one 
hand, then the leg of the same side is affected, later the opposite 
leg and lastly the other hand. The order is not regtilar and in 
some cases the tremor is confined to the hands or feet alone, or 
to the extremities on one side. Late in the disease the head and 
neck muscles are affected and there is a coarse shaking or nod- 
ding of the head with tremor of the lower jaw and lips. The 
tremor rate is from four to seven per second but it may be tem- 
porarily controlled by the will and it ceases during sleep. Ex- 
citement and fatigue do not increase the rate but they increase 
the extent of the oscillations until they become a coarse tremor 
or shake. 

"Paralysis agitans sine tremore, " paralysis agitans without 



PROGRESSIVE BULBAR PARALYSIS 379 

tremor, is occasionally met with. The name is a misnomer, for 
while there is progressive weakness there is never complete loss 
of power, and without tremor there is no agitation. 

In these cases there is progressive muscle rigidity, generally 
marked on one side and but slight on the other, and later the 
characteristic attitude appears. A peculiarity of the gait is an 
apparent inability or lack of energy to make the first step when 
intending to walk. It then requires some powerful mental 
impression as a threat, or some external impetus, to start him. 

Diagnosis. — When the disease has so far advanced that the 
characteristic attitude becomes a prominent feature error in 
diagnosis is impossible. 

Before this time it may be mistaken for senile tremor (see 
Senile Tremor) and other tremor diseases. Multiple sclerosis and 
hysteria are extremely rare in old age. The different character 
of the tremor and the absence of muscle stiffness will exclude 
these and also the toxic tremors (lead, mercury, alcohol, etc.). 

Treatment. — The disease is incurable. It progresses slowly 
and while cases have succumbed within a year after the initial 
symptoms were observed, the ordinary diuration is from five to 
fifteen years. 

Hyoscine in i/300-grain, or hyoscy amine sulphate in i/i co- 
grain, doses, hypodermically, will relieve the tremor and muscle 
stiffness, but the dose must be constantly increased and the drug 
finally discontinued when toxic effects appear. Duboisin may 
then be substituted and given in doses of 1/150 grain, gradually 
increased. Hydrotherapy and electrotherapy are of temporary 
utility in arresting the progress of the disease. Arsenic has a 
more permanent effect and should be given until the physiolog- 
ical effects of the drug compel its discontinuence. Nux vomica 
which has been recommended as a tonic seems to intensify the 
i tremor and muscle cramps. When the patient becomes bed- 
i ridden measures must be employed to prevent hypostatic 
i congestion and edema. 

PROGRESSIVE BULBAR PARALYSIS 

Glossopharyngolabial paralysis is a rare disease, occurring 
most frequently in advanced life. It is a symmetrical paralysis 
affecting the muscles of the lips, tongue, palate, pharynx, 
i larynx and the muscles of mastication. 



380 PATHOLOGICAL OLD AGE ^ 

Etiology. — The cause is unknown. Supposed causes are 
shock, strong emotions, cold, overexertion of the muscles supplied 
by the hypoglossal and glossopharyngeal nerves, injtiry and 
infections. 

Pathology. — There is a degeneration of the motor nuclei of 
the medulla and pons, the ganglionic cells atrophy, the hypo- 
glossal, glossopharyngeal, facial, vagus, accessory and sometimes 
trifacial motor trunks are degenerated and the pyramidal tracts 
of the cord are occasionally involved. In some cases the ante- 
rior horns are atrophied and the lateral columns are degenerated, 
and we find the same lesions as observed in progressive muscular 
atrophy and amyotrophic lateral sclerosis, but the symptoms of 
these diseases are absent or appear late. 

Symptoms. — The symptoms are a progressively increasing 
difficulty in speech, phonation, chewing and swallowing, later 
difficulty in respiration, a fibrillary tremor of the tongue and 
muscles of mastication and waste of the muscles involved. The 
speech becomes difficult, due to gradual paralysis of the tongue, 
and the Unguals are slurred over. Later the same difficulty arises 
with the labials and the speech becomes indistinct, obscure and 
finally incomprehensible. At the same time progressive paraly- 
sis of the larynx and vocal cords makes phonation difficult and 
the voice becomes weak, finally dropping to a monotonous 
hoarse whisper. The tongue slowly loses its motility and be- 
comes completely paralyzed. Owing to the paralysis of the lips, 
the mouth cannot be closed and saliva drivels out. The patient 
is unable to whistle. The soft palate drops, fin"ther interfering 
with speech and deglutition. Weakening of the muscles of 
mastication makes it impossible to move the jaws from side to 
side and the paralysis of the muscles of deglutition prevents swal- 
lowing, the food remaining as a bolus in the posterior part of the 
mouth while fluids run back through the nostrils. When the 
disease is fully developed the lower half of the face is expression- 
less, the lower lip and corners of the mouth hang down and the 
countenance presents a very peculiar appearance, the lower part 
being paralyzed while the upper part is active. The mind is 
unimpaired. There is usually tachycardia, with dyspnea and 
with exaggerated facial reflexes. 

Progressive bulbar paralysis is distinguished from hemor- 
rhage, thrombosis, and embolism in the medulla, by its slow 



PSEUDOBULBAR PARALYSIS 38 1 

advent, the other conditions appearing suddenly. Tumors in 
the medulla produce more extensive paralysis beside intense 
headaches. 

Treatment. — There is no known treatment, death usually 
occurring in a few 3^ears from asthenia. It may occur earlier, 
however, from aspiration pneumonia, respiratory paratysis or 
other complicating disease. Strychnine, arsenic, iodides, ni- 
trate of silver, the galvanic and faradic currents have all been 
used with apparent momentary improvement, but no cure has 
ever been reported. 

ACUTE BULBAR PARALYSIS 

This is a form of apoplexy which resembles the progressive 
bulbar paralysis in its clinical picture but differs from the latter 
in its sudden onset. It occurs as the result of a hemorrhage into 
the pons by breaking down of the tissue after thrombosis or 
emboHsm in the basilar or vertebral artery, or in one of their 
branches had taken place. Thrombosis produces premonitory 
symptoms such as vertigo, tinnitus, headache, insomnia, etc. 
The onset of the disease is abrupt. A momentary vertigo and 
vomiting is follow^ed by convulsions. When these pass away 
there remains a glossophar\mgolabial paralysis vrith all the 
symptoms described under progressive bulbar par ah' sis, and 
frequently also a hemiplegia or paraplegia. The paralysis of 
the facial muscles, and muscles of deglutition, mastication and 
speech, is not always symmetrical, and where there has been 
an extensive extravasation of blood the muscles of the upper 
part of the face, including the motor muscles of the eyes, may 
become involved. The disease, when extensive, is rapidly fatal; 
in mild cases recovery is possible. 

Treatment as for apoplexy. 

PSEUDOBULBAR PARALYSIS 

In this disease the symptoms of bulbar paralysis set in after 
several apoplectic attacks during which other forms of paralysis 
had occurred. The ordinary lesions of cerebral apoplexy, 
cerebral hemorrhages, are foimd, and in most cases there are 
minute extravasations in the pons and medulla. The disease 



382 PATHOLOGICAL OLD AGE 

when fully developed presents the symptoms of cerebral arterio- 
sclerosis, cerebral apoplexy and progressive btilbar paralysis 
and is really a combination of the three diseases. The fifth 
group takes in diseases which do not fit in any of the preceding 
groups. 



DISEASES UNINFLUENCED BY AGE OR RARE IN 

OLD AGE 

INFECTIOUS DISEASES 

The resistance to bacterial influences is apparently greater 
in old age than in earlier life. This is opposed to the general 
view that resistance is lowered in the aged, but the simple fact 
that infectious diseases rarely attack old persons even in epidem- 
ics, would seem to substantiate this statement. Whether this 
resistance is due to an increase in opsonins, more active phago- 
cytosis or a change in the body tissues whereby the tissues 
become an unsuitable field for the propagation of the germs, 
is unknown. Other possible explanations are an inherent 
resistance in senile cells, a lower body temperature, less exposure, 
etc. The only diseases of this character that are relatively as 
frequent in the aged as in maturity are erysipelas, variola, influ- 
enza, typhus and cholera. The frequency of erysipelas on the 
lower limbs is readily accounted for by the presence of surface 
lesions, such as excoriations, scratches, eczema and ulcers in 
that locality. The frequency of influenza is due to the preva- 
lence of chronic bronchitis, the impaired mucous membrane 
being a suitable field for the growth of the pathogenic bacillus. 
That variola frequently attacks the aged in epidemics is proba- 
bly due to the fact that the immunity secured by vaccination 
in childhood wears off in the course of years and the aged are 
hence more susceptible than younger persons who have been 
more recently vaccinated. The greater susceptibiHty of the 
old to typhus is probably due to the general debility which 
lessens resistance to this disease and the same cause with the 
senile changes in the intestines will account for the relative 
frequency of cholera in the aged. Cholera and typhus are 
infrequent in this country, however, and for this reason cases 
among the aged here are of the greatest rarity. 



INFECTIOUS DISEASES 383 

The acute infectious diseases when occurring in the aged 
present some peculiarities. They do not run a typical course 
nor present a typical temperature curve, and the temperature is 
rarely as high as in m.aturity. In the eruptive diseases the 
eruption is milder and may be absent, but constitutional symp- 
toms are usually graver and death frequently ensues in cases 
which are apparently mild. In the graver diseases like typhus, 
cholera and variola, death usually occurs within a few days 
after the onset of the disease. In the chronic infectious diseases 
and in those that do not run a definite course the symptoms are 
usually milder but more persistent than in earlier life. 

It is assumed that the physician is familiar with the ordinary 
etiological factors, symptoms, signs and therapeutic measures 
employed in infectious diseases in maturity. Where differences 
in these factors in maturity and senility exist, they will 
be described, but otherwise the etiology, symptoms, signs and 
treatment will be omitted. Such rare diseases as malta fever, 
miliary fever, etc., and diseases which are not known to occur 
in seniHty such as rotheln, varicella, etc., will receive no further 
consideration. In the differential diagnosis between diseases 
giving similar symptoms, only pathognomonic symptoms and 
signs where such exist, or else a few cardinal symptomatic differ- 
ences will be noted. As a rule the temperature range of acute 
infectious diseases is lower in the aged, the eruption in the 
exanthemata is lighter, more scattered and the spots fewer in 
number. They come on later, and whereas they appear in 
successive crops in maturity, in old age there is only a single crop. 
The cerebral and nervous symptoms are usually much more 
pronotmced than in earher life, the prostration is more severe, 
complications are more frequent, and the grave diseases, hke 
typhoid and variola, are more fatal. In diseases in which the 
bronchial mucous membrane is seriously involved, bronchial 
and pulmonary complications frequently end in death. Many 
cases are followed by incomplete recovery, mental and physical 
impairment, and foci susceptible to later diseases are retained. 

Scarlatina has been reported in the aged. It appears in a 
mild form, however, and the temperature is but slightly elevated ; 
the eruption is light and the complications of early life are usually 
absent or are mild. The pharynx and tonsils may be reddened, 
but there is never the scarlatinal diphtheria nor any cervical 



384 PATHOLOGICAL OLD AGE 

gland involvement, and rarely the typical strawberry tongue. 
Desquamation sets in early, usually before the end of the first 
week. Cases of scarlatina sine exanthemate also occur in the 
aged. These cases present the buccal and pharyngeal lesions 
with fever but not the rash. Desquamation occiu-s as in ordi- 
nary scarlatina. The prophylactic treatment is as in childhood. 
The only treatment during the disease is rest, the reduction of 
temperature, if high, by means of warm baths, maintenance 
of the strength of the heart and of the organism as a whole, and 
hygienic and dietetic measures. As a mouth wash and gargle 
nothing equals a solution of peroxide of hydrogen. 

Measles occur rarely in the aged and do not differ from 
the same disease in earlier life, though they appear in a much 
milder form, the conjunctival symptoms are milder, but the 
irritation of the bronchial mucous membrane is more severe 
and may lead to a bronchopneumonia. This is the only danger 
in measles but it is ever present until the disease has entirely 
disappeared, and it forms the basis of the usually unfavorable 
prognosis. The disease itself is mild, the rash is slight, with but 
little elevation of temperature, but there is a profound feeling 
of malaise. The symptoms diminish in severity after the first 
day and may disappear entirely within two or three days. If 
there is an old bronchitis present, a capillary bronchitis by 
extension is almost unavoidable. Cardiac disease or arterio- 
sclerosis complicating measles increases the asthenia and makes 
the prognosis more unfavorable. The treatment is hygienic 
and symptomatic. If there is conjunctivitis the room should 
be darkened. For the irritating cough with which the disease 
usually begins codein, heroin or dionin should be given and 
menthol and eucalyptol should be inhaled. The disease being 
usually of short duration, tonics and cardiac stimulants are not 
required. The danger of extension of the bronchitis to the 
vesicles can be lessened by the inhalation of steam through an 
inhaler. 

Diphtheria may occur in the aged and is then usually so mild 
in its subjective symptoms that it may pass unnoticed. There 
may be little or no elevation of temperature, no pain, swelling 
or redness of the tonsil, nor any other symptom than the exudate. 
The exudate does not differ from the diphtheritic exudate of 
early life, but it is more tenacious and may persist for weeks, 



iil< 



DIPHTHERIA :^Ss 

in spite of the use of antitoxin. The mildness of the symptoms 
is, however, a source of danger as its presence in the fauces may 
be overlooked until the disease has advanced to the larynx. 
Laryngeal diphtheria, which is almost always fatal, begins 
with hoarseness, cough and a feeling of irritation in the larynx 
as though there were a bit of tenaceous mucus which the patient 
is unable to bring up. The exudate increases downward over 
the trachea, causing spasmodic contractions, dyspnea, cyanosis 
and death. In some cases the cough loosens a fragment of 
exudate which drops into the bronchus, blocking a tube and caus- 
ing sudden dyspnea and suffocation. Death is usually not due 
to the virulence of the diphtheria bacillus but to the local obstruc- 
tion, or to exhaustion from coughing. In gangrenous diphtheria 
a gangrenous ulcer appears upon the tonsil, sometimes within 
a day or two after the initial malaise, the opposite side is rapidly 
involved and the adjoining tissue in the pharynx, uvula and soft 
palate may also become gangrenous. There is an abundant 
secretion of foul-smelling pus, sometimes mixed with blood, 
grave constitutional symptoms appear, such as extreme exhaus- 
tion, weak, irregular pulse, shallow breathing, headache and 
albuminous urine, containing casts, etc. There is rarely any 
fever or involvement of the cervical glands. The disease is 
almost always rapidly fatal. The diagnosis of diphtheria is 
simple and depends upon the presence of the pathogenic bacillus. 
The usual antitoxin treatment applies to the aged exactly the 
same as to yotmger individuals, but it is never necessary to 
exceed 3000 units, given in a single dose except in laryngeal 
cases. Larger or repeated doses will not hasten the removal of 
the exudate which may persist for weeks, while a single dose 
of 1000 units may suffice to prevent laryngeal involvement. 
Diphtheria antitoxin is useless in gangrenous diphtheria, the 
condition being due to a mixed infection in which a virtilent 
strain of streptococci or staphylococci is responsible for the 
gangrene. A mixed or autogenous vaccine is required in these 
cases. In laryngeal diphtheria antitoxin should be used in 
doses commensurate with the severity of the symptoms. 

For the removal of the membrane a 10 per cent, solution of 

papayotin or trypsin will give the most rapid result. It should 

be swabbed over the patch every hour or two. The membrane 

will re-form but the frequent application will prevent the exten- 

25 



386 PATHOLOGICAL OLD AGE 

sion of the growth to the larynx. A solution of peroxide of 
hydrogen can be employed locally, but if either of the enzymes 
is employed the peroxide of hydrogen must be used afterward, 
never before the other. Lactic acid will also remove membrane. 
Chlorate of potash is useless in diphtheria. The hygienic and 
dietetic regulations need no special consideration, except that 
food should not be taken hot, and precautions should be taken to 
prevent the spread of the disease. Internal medication is not 
required except where complicating symptoms appear. 

Whooping cough differs in some minor factors from the dis- 
ease in infancy. After a primary catarrhal period lasting from 
two to three weeks, during which there is a bronchial catarrh, 
constantly increasing in intensity, the second period sets in 
with a convulsive cough. The paroxysms of coughing are simi- 
lar to those of infancy, but they occur more frequently during 
meals, the movements of deglutition apparently provoking the 
attack. During the cough of the aged, the characteristic whis- 
tling inspiration observed in infants is absent and vomiting which 
is a frequent accompaniment of the cough in the young does not 
occtir in the old. After an indefinite period the spasmodic at- 
tacks cease and a bronchial catarrh is retained which forms the 
third period of pertussis in the aged. Complications are rare, 
and are almost always due to the irritation of the larynx and the 
strain of coughing. In rare cases brochopneumonia will occur 
during the disease, or may follow it. The treatment is as in 
infancy. A change of climate will sometimes hasten the cure. 
The medicinal measures usually given in infancy must be given 
in increased doses in seniHty, but vasoconstrictors must be 
avoided. 

Mumps has been reported in the aged. The essential fea- 
tures of the disease are the same as those of earlier life but the 
orchitis which generally accompanies the disease in maturity 
does not appear in old age. The disease is usually mild, but a 
few cases have been reported in which death had occurred soon 
after cerebral symptoms, delirium and coma appeared. The 
treatment is purely symptomatic unless suppuration occurs when 
a free incision is indicated. The inunction with a 5 per cent, 
solution of oleate of mercury may shorten the inflammation. 

Malaria is infrequent in the aged, either as a primary attack, 
or as a recrudescence of an earlier one. The disease differs 



YELLOW FEVER 387 

slightly in its symptoms from that of earlier life. The tempera- 
ture is rarely above 103°, and where the first attack occurs late 
in life, there is no apparent enlargement of the spleen. Other 
symptoms, such as headache, malaise, aches in the bones, joints 
and back, thirst, anorexia, etc., may be aggravated. Remittent 
jever and pernicious malaria are extremely rare and the latter is 
almost always rapidly fatal. The ordinary intermittent fever is 
readily recognized by the regularity of its appearance in the 
tertian or quotidian form. In all cases Osier's dictum, ''an 
intermittent fever that resists quinine is not malaria," holds 
good. 

Chronic malaria or malarial cachexia follows repeated attacks 
of one of the acute forms and is usually fatal in the aged. The 
course and treatment of malaria is the same as in younger in- 
dividuals. In the severe forms of remittent and pernicious fever 
quinine alone is of little service, except to reduce the temperature 
and this is rarely high in the aged. The quinine should be given 
in these cases combined with gr. 1/40 of arsenic three times 
daily or with methylene blue in 2 -grain doses, while other symp- 
toms should be treated symptomatically. 

Yellow fever appears infrequently and when it does occur, 
it presents the same symptoms and takes the same course as in 
younger individuals. It is probable that the comparative rarity 
of yellow fever and primary attacks of malaria in the aged is due 
to the character of the senile skin which makes it less attractive 
to the pathogenic mosquito than the skin of yoimger individuals. 
The temperattire in yellow fever is rarely high, and vomiting may 
be absent during the entire disease, while the icterus is not as 
pronounced as in younger individuals, probably due to the darker 
and more weather-beaten skin. Other symptoms such as head- 
ache, pain in the bones, joints, back and epigastrium, occur as in 
maturity. The stage of initial fever may be prolonged, the 
remission short and the reaction protracted. Most deaths occur 
during the stage of reaction and are due to profound impairment 
of the heart, kidneys, or liver. Some deaths are due to pulmon- 
ary edema following hypostatic congestion, or to general ex- 
haustion. The diagnosis is readily made by the distinguishing 
features pointed out by Guiteras, the facies, early albuminuria 
and a slowing pulse, with a constant or rising temperatiire. 
There is a high hemoglobin percentage, and the blood coimt 



388 PATHOLOGICAL OLD AGE 

shows an increased number of red cells and diminished leuco- 
cytosis. 

The treatment of yellow fever is symptomatic and hygienic. 
Quinine has apparently no other effect than to reduce the tem- 
perature, and for this purpose it is the most reliable antipyretic 
we have. The bowels should be thoroughly cleared, using, 
preferably, castor oil ; calomel should not be used. As intestinal 
antiseptics, we can employ salol and the sulphocarbolates. 
Nothing will stop the black vomit when it occurs, but the ten- 
dency to vomit can be diminished by small doses of cocaine. 
Should a reaction set in, the bile salts can be given to replace the 
diminished bile, hot fomentations over the kidneys and saline 
diuretics largely diluted should be employed in anuria, and 
heart tonics where the heart becomes weak, as it usually 
does in yellow fever. Spartein is the proper drug when the 
heart becomes weak and slow. Concentrated and predi- 
gested foods should be given throughout the disease and 
during convalescence. 

Dysentery does not differ in its essential features from the 
dysentery of earHer life. Both the bacillary and the amebic 
forms occur in the aged, the two forms presenting the same 
symptoms. The bacillary form generally begins with chills and 
a slight elevation of temperature, after which the intestinal 
symptoms appear. These are frequent, small, painful dejections, 
abdominal cramps, tenesmus and straining and the passage of 
mucus and blood. There is rapid prostration and emaciation, 
great thirst and often rapid exhaustion. The disease is more 
fatal in the aged than in younger individuals and, unless con- 
trolled, a fatal issue may be reached in a few days. Since the 
introduction of the an ti dysenteric serum the death rate has 
been greatly lowered. The amebic form is usually slower in 
its onset than the other, it is more protracted and unless death 
results from toxemia, or from perforation of the bowel, it' 
usually passes into the chronic form of dysentery. In this 
form there are remissions and exacerbations, the remissions 
being usually marked by alternating constipation and diarrhea. 
During an exacerbation there is a return of the usual symptoms 
of acute dysentery. During the remissions there may be a 
lienteric diarrhea, or there may be semisolid or fluid stools 
usually containing mucus, but rarely blood, while tenesmus 



DYSENTERY 389 

and straining may be absent. In this form of dysentery there 
is progressive emaciation, the individual becomes weaker and 
dies from exhaustion, the fatal issue being sometimes reached 
in a few weeks; more often, however, it does not ensue until 
several months or a year or more have elapsed. Complete 
recovery is extremely rare in advanced life. Numerous com- 
plications arise in the course of acute and chronic dysentery. 
These are due in part to the loss of blood and water, in part 
to the toxemia and septic infection and in part to the local 
destruction of tissue. The gangrenous process may extend 
through the wall of the bowel and cause perforation and speedy 
death. Hepatic abscess frequently follows amebic dysentery 
and abscess and gangrene in other tissues are occasionally 
observed. Septic inflammation may occur in any tissue and 
other bacterial diseases are sometimes associated with it. 
For the bacillary dysentery we have an antidysenteric serum 
which is curative in most cases but it is useless in the amebic 
form. In addition to the serum, other therapeutic measures 
are employed to produce a cessation of the discharges, relieve 
the distressing symptoms, and maintain the strength of the 
patient. The first indication is to clear the bowel with castor 
oil. After this has been accomplished the Cautani's enteroclysis 
solution should be employed as described under cholera. For 
the relief of the diarrhea we can use tannalbin, the sulphate or 
arsenite of copper, zinc siilphate, nitrate of silver, or any of the 
metallic astringents. Ipecac is probably the oldest and best 
drug for the control of the diarrhea. The dose is lo to 15 
grains every hour for fotir hours, given preferably in milk. 
As this may have an emetic effect, the patient must remain 
strictly in the recumbent position and 10 minims of tincture 
iOf opium should be given before starting the ipecac treatment. 
I If there is pus in the discharges, salol or the sulphocarbolates 
[Should be given with the astringent. Belladonna given in a 
suppository will generally relieve the tenesmus and morphine 
may be used to relieve pain and insomnia. Magnesium sul- 
iiphate often relieves the distressing symptoms. The various 
complications require appropriate medication. The dietary 
treatment is important, as improper food will aggravate the 
disease. The food should be liquid and concentrated, corre- 
jsponding with the character of the stools. If the stools are 



390 PATHOLOGICAL OLD AGE 

watery the food shoiild be liquid. With semisolid stools 
give mushy food, and no solid food till stools are natural. 

Plague does not occur in the United States except in isolated 
cases of immigrants coming from plague infested countries. 
In coimtries where it does prevail it is seldom found among the 
aged, and when they are attacked, it appears in a milder form 
than it does in maturity. According to Ortner the death rate 
is not higher, indeed it may be lower than in earlier life. This 
would tend to confirm the view that the aged organism is more 
resistant to infection than the younger. 

Cholera when epidemic, attacks the aged as rapidly as 
younger individuals and is much more fatal, death occurring 
in almost every case, even when the symptoms are mild. The 
disease does not differ in its essential features from the disease 
in maturity. The period of incubation may be prolonged, but 
the onset and course of the disease are as in younger individuals. 
The discharges and vomiting soon induce profound prostration 
and collapse. In some cases collapse sets in before the choleric 
rice-water diarrhea has appeared; in most cases collapse occurs 
during the algid stage. Few aged patients survive this stage 
and most of those that do, succumb to a succeeding typhoid 
condition. 

There is no specific treatment for cholera and all our efforts 
must be directed to counteract threatening symptoms. The 
vomiting may sometimes be checked by cocaine in i/8- to 1/4- 
grain doses, chloroform in 3 -minim doses or morphine in 1/8- 
grain doses, hypodermically. The usual treatment for the diar- 
rhea is first a large dose of castor oil followed two hours later by 
10 minims of tincture of opium. Cautani's enteroclysis solution 
for irrigation of the bowels should be used three or four times a 
day. This solution consists of tannic acid 21/2 drams, tincture 
of opium 30 minims, mucilage of acacia 3 ounces, to 4 pints of 
water. It is injected slowly at a temperature of 105°. For 
the muscle cramps, menthol and chloroform liniment, combined 
with massage, may give temporary relief. The usual heart 
tonics, camphor, caffeine, cactin, etc., must be used from the 
onset, reserving strychnine for the inevitable emergency during 
the algid stage or earlier. Dermoclysis and intravenous injec- 
tions of normal saline solution are used when collapse sets in. 
Salol and the sulphocarbolates should be used as intestinal 



1 



VARIOLA 391 

disinfectants from the onset of the disease. Concentrated and 
predigested foods are necessary. 

Cholerine, a mild cholera with slight muscle cramps, little 
or no vomiting and colored diarrheal discharges, is treated like 
the grave form. 

Variola in the aged rarely follows the classical course. The 
prodromal period is more severe and prolonged. The cerebral 
symptoms simulate early meningitis, and may proceed to 
delirium and coma. There is always a weak, rapid pulse and 
often shallow rapid respirations. The initial symptoms are 
slight chills, rapid rise in temperature, prostration and pain in 
the lumbar region. The initial eruption is usually absent and 
the true eruption of variola appears as rose- colored macules, 
few in number and more scattered than in earlier life. Few of 
these macules proceed beyond the papular stage and fewer 
still become fully developed variola pustules. The disease is 
protracted in the aged, and in some cases vesicles do not ap- 
pear until the tenth day and are converted into pustules 
three or four days later. The further progress of the disease 
is as in younger individuals, the whole course, however, being 
slower. 

The disease is extremely fatal in the aged, the confluent and 
the hemorrhagic forms being invariably so. Many cases die 
during the period of invasion, while others succumb as soon as 
the stage of suppuration is reached. The complications include 
meningitis, pneumonia or bronchopneumonia, pleurisy, gan- 
grene, bedsores, various forms of mucous inflammation, pul- 
monary edema, etc. The prodromal stage and the initial stage 
of variola, before the appearance of the eruption, is like the pro- 
dromal and initial stages of other acute infectious diseases and 
it is often impossible to differentiate between them. Some 
presumptive diagnostic points have been given, but until the 
appearance of the macules — which generally first show upon the 
forehead and wrists — a positive diagnosis is impossible. After 
their appearance there ought to be no further doubt, as the 
only disease giving a similar history of invasion and a similar 
rash being measles. This is readily differentiated by the milder 
symptoms, catarrhal and conjunctival inflammation, the more 
profuse rash and absence of lumbar pain, etc. In variola 
there is a sudden drop in the temperature as soon as the erup- 



392 PATHOLOGICAL OLD AGE 

tion appears, while in all other exanthemata the appearance of 
the eruption is marked by a slight rise in temperature. 

Treatment of smallpox is symptomatic and hygienic. 
There is no specific treatment and all that can be done is to 
treat symptoms, minimize the causes of complications and main- 
tain the strength of the individual. The distressing or danger- 
ous symptoms are the fever, cerebral symptoms (headache, 
delirium, coma), circulatory disturbance, pain, pruritus and 
exhaustion. 

The fever can sometimes be controlled by antipyretics, 
especially acetphenetidin and others of the coal-tar products, 
but these are cardiac depressants and must therefore be com- 
bined with ammonia carbonate. The usual combination with 
caffein is irrational, as the caffein is a slow-acting heart stimu- 
lant, while the depressants act rapidly. Quinine is a safe anti- 
pyretic in all infectious diseases, but it is slow in action. The 
delirium should be controlled by the use of bromides and, if 
these fail, codein or morphine must be used. If the heart 
becomes weak, we must use cardiac stimulants, preferably 
caffein or camphor, leaving the more powerful stimulants, 
like strychnine, ether, strophanthus, etc., for emergencies. 
Nothing will take the place of cocaine as a local application for 
the intolerable itching that sometimes accompanies the erup- 
tion. For exhaustion we should proceed as in typhoid fever 
allowing, however, greater leeway in the selection of food. The 
hygienic and prophylactic measures are as in typhoid fever. 

Varioloid occurs during an epidemic in persons who have 
been vaccinated. It is virtually a mild variola and as such 
can attack the aged as well as younger persons. The course 
of the disease is mild, the siu-face lesions rarely proceeding to 
the vesicular stage. The cerebral symptoms and exhaustion 
are, nevertheless, severe in the aged and may cause death. 
The treatment is similar to that of the graver disease. 

Typhoid fever is infrequent in the aged. When it does 
occur its early manifestations resemble the early symptoms of 
pneumonia and it is often impossible to differentiate them 
without the Widal reaction or blood test. It generally begins 
after a prolonged prodromal malaise with slight chills, irregular 
fever and rapid prostration. The classical symptoms and 
course are rarely found in the senile cases. Instead of the 



TYPHOID FEVER 393 

typical temperature curve there is usually an irregular tem- 
perature, sometimes remittent, sometimes intermittent, seldom 
going above 103°, more often remaining in the neighborhood of 
102°; Instead of the usual progressive rise in temperature 
and increasing severity of symptoms for a week, followed by a 
week of maximum intensity of symptoms with a steady decline 
during the next week, the disease in the old runs an irregular 
protracted course lasting four or five weeks. The period of 
maximum intensity is about the end of the second week. The 
pulse shows some peculiarities, being often dicrotic, and, while 
in younger cases the rate is comparatively low, even when the 
fever is high, in senile cases it is generally high and may reach 
120 or more with a temperature of 102°, and slight causes, 
such as a change of position, will cause a rapid rise of 20 or 30 
beats per minute which drops again a minute or two later. 
The eruption is usually lighter in color, smaller, and scattered, 
and may escape detection altogether. Instead of appearing 
in successive crops the first crop appears at the end of the 
first week and may disappear in a few days or may persist 
throughout the disease. The abdominal symptoms frequently 
differ markedly from the classical symptoms as they appear 
in younger individuals. The spleen shows no enlargement. 
There is a progressively increasing tympanites which may set 
in during the first few days of the disease and which is more 
pronounced than in maturity; constipation is the rule, and 
the typical "peasoup" diarrhea is infrequent. There is some 
pain in the ileocecal region and occasionally in other localities 
about the abdomen. There are usually sordes about the teeth 
and tongue and the latter is dry, brown, often cracked. In 
severe cases there is extreme mental and physical depression, 
the patient is semicomatose or there is a low muttering delirium, 

5 the respiration is shallow, heart weak and rapid, and the whole 
appearance that of the prostration preceding death. In some 
cases there is a tremor of the hands, more often there is an 

I unconscious picking at the bed-clothes, and twitching of the 

I tendons, or else there is a complete relaxation of the limbs as in 
motor paralysis. The gravity of the symptoms increases until 
the end of the second week. Most senile typhoid fever cases 
succumb at this time, the prostration leading to collapse and 

ij death. In the cases that survive this period, there is a gradual 



394 PATHOLOGICAL OLD AGE 

improvement, first seen in the cerebral symptoms. There is 
also a clearing of the tongue, a conscious effort to swallow, and 
the patient begins to sleep naturally. Later appetite returns 
and with it increasing strength. Constipation alternates with 
diarrhea, the meteorism disappears, the spots fade, and the 
patient is free from pain. Convalescence is slow and in most 
cases the complications that have occurred during the progress 
of the disease retard complete recovery for weeks or months 
after the disappearance of the disease. The most frequent 
complications are pulmonary edema following hypostatic con- 
gestion, bedsores, intestinal hemorrhage, cardiac exhaustion, 
bronchitis, pneumonia and perforation. Pulmonary edema 
and perforation are rapidly fatal. Intestinal hemorrhage is 
almost always fatal, as the aged individual cannot stand the 
loss of blood, and dies of exhaustion. Cardiac exhaustion can 
sometimes be overcome by the use of rapidly acting cardiac 
stimulants. A complicating pneumonia is generally fatal, either 
through the toxemia itself, or through pulmonary edema. 
The bronchitis that occurs in typhoid fever is usually purulent, 
which may lead to pulmonary abscess or gangrene or to a cap- 
illary bronchitis. There is occasionally an acute nephritis, 
and various ulcerative, hemorrhagic and degenerative condi- 
tions may result from the typhoid infection. 

The diagnosis of typhoid fever in the aged is sometimes 
difficult unless the bacilli are found, or the Widal test is made. 
The clinical manifestations are often misleading, owing to the 
irregular course of the disease ; lower temperattn-e, light eruption, 
absence of splenic enlargement and frequent absence of the 
"peasoup" diarrhea. Mononuclear leucopenia exists in ty- 
phoid fever unless complicated by a disease in which leucocy- 
tosis occurs. Other diseases in which a leucopenia occurs 
are readily differentiated from typoid fever or do not occur in 
the aged. These diseases are measles, German measles, small- 
pox, mumps, malaria, tuberculosis, influenza, leukemia and 
pseudoleukemia. The leucocyte count is of importance, as 
it enables one to distinguish an early stage of typhoid fever 
from sepsis, pneumonia, appendicitis and meningitis. 

The early cHnical manifestations of typhoid may simulate 
pneumonia, sepsis or meningitis. The prostration seen in 
typhoid may be seen in pneumonia or any other acute 



TYPHOID FEVER 395 

grave disease. In the serous inflammations — peritonitis and 
pleurisy — the mind is clear, in meningitis there is intense head- 
ache, photophobia, tinnitus, rapid prostration, and the mind is 
dull, unless there is delirium, when it is active. There is 
besides generally a history pointing to cerebral disease, while 
abdominal symptoms that are always found in typhoid fever 
are absent. The onset of pneumonia resembles the onset of 
typhoid fever. In the absence of a Widal test the early diagno- 
sis based upon symptoms and physical signs must be deter- 
mined by the presence or absence of the symptoms and signs 
of pneumonia. The cerebral symptoms are more pronounced 
in typhoid, and cough if not present at the onset of the disease 
does not appear during the first week, while in pneumonia it 
appears T^dthin the first forty-eight hours. After the second 
day the physical signs in most cases of pneumonia are suffi- 
ciently pronounced to determine the diagnosis. Other diseases 
occurring in the aged which begin with prostration, chills, fever 
and a profound malaise are sepsis, influenza and tuberculosis. 
The invasion of miliary tuberculosis is slow and never as 
severe as typhoid. The early bronchial symptoms of influenza 
do not appear in typhoid until the end of the first week; the 
tongue is red and moist, in influenza the skin is reddened, there 
is often a herpetic eruption and generally a copious pirrulent 
or mucopurulent expectoration. The early differential diagnosis 
between sepsis and typhoid in the aged is often difficult and 
even if the eruption appears it is not always a certain pathog- 
nomonic sign as roseate macules are occasionally observed in 
sepsis and the beginning of typhus. The diagnosis of sepsis 
is often based upon the presumptive signs of a pronounced initial 
chill, pains in the bones, herpes, hemorrhagic macules, rapid 
pulse and respiration, while rapid profound prostration with 
cerebral symptoms, roseate papules, and eventual intestinal 
hemorrhage point to typhoid. Any of these presumptive symp- 
toms and signs may occur in either disease and we must often 
make a diagnosis by the prominence and number of symptoms 
found most frequently in either disease. In some cases a 
positive diagnosis cannot be made without examination of 
blood, luine and feces. Typhoid may also be mistaken for 
paratyphoid, typhus or epidemic cerebrospinal meningitis. 
The last two are very rare in the aged, appear only in an epi- 



396 PATHOLOGICAL OLD AGE 

demic form, and proceed to a very grave condition within 
forty-eight hours. Cerebrospinal meningitis presents a pathog- 
nomonic pain along the spine with stiffness of the muscles of 
the neck. Typhus begins with a chill, there is high fever, 
rapid and profound prostration and the eruption is scattered 
over the trunk and not confined to the abdomen. The eruption 
consists of rose-colored macules with hemorrhagic centers. 
In paratyphoid, which is a rare disease, there is an initial chill, 
the cerebral symptoms are milder, while the intestinal symptoms 
are more pronounced. There is usually early vomiting and 
diarrhea, frequently herpetic eruptions, irregular temperature 
and the whole course of the disease is milder. 

The prognosis of typhoid fever in the aged is always grave, 
even in cases where the symptoms are mild. The chief sources 
of danger are the prostration leading to collapse, pulmonary 
edema following hypostatic congestion, intestinal hemorrhage 
and perforation, and pulmonary and renal complications. 
Protracted cases produce general exhaustion and a relapse is 
almost always fatal. Many deaths are due to complications 
other than pulmonary and renal involvement. 

Treatment. —There is no positive method of aborting, short- 
ening or curing typhoid fever, the typhoid vaccines being still 
experimental, and therapeutic measures must be directed 
toward amelioration of symptoms and prevention of complica- 
tions. The most important of the therapeutic measures in 
maturity is hydrotherapy applied in the form of cold baths 
given according to the Brand or Baruch method. In senile 
cases a cold bath is an extremely dangerous experiment. The 
shock may produce collapse, while if the temperature of the 
bath has been gradually lowered, there may be no reaction in 
spite of friction, hot water bottles, hot stimulating drinks, etc. 

If the rectal temperature is 103° or above, cold sponging may 
be tried, but if the first application of cold water (never ice in the 
aged) produces a shock it must be discontinued or tepid water 
substituted. The sponging can be repeated every two or three 
hours, but the patient must be moved as little as possible, and 
abdominal manipulation must be avoided. The usual practice 
of beginning the treatment of typhoid fever by giving repeated 
small doses of calomel can serve no other useful purpose than 
to produce catharsis. It has no influence upon the disease. 



TYPHOID FEV-ER 397 

If there has been constipation a single dose of castor oil to which 
5 grains of salol, betanaphthol, or soda sulphocarbolate and 2 
grains of the bile salts have been added, vnll act better than 
calomel. If there is diarrhea a powder containing dionin 1/6 
grain, salol 5 grains and bismuth sub nitrate 10 grains should 
be given, and repeated if necessary in three or four hours. 
Salol and the sulphocarbolates (Waugh Abbott formula) 
can be used as intestinal antiseptics throughout the disease. 
In hyperpyrexia quinine \\ill give the most permanent re- 
sults, but if quick action is necessary, as in delirium due to 
high temperature, we m.ust fall back upon the coal-tar prepara- 
tions, preferably acetphenetidin or antipyrin. A temperature 
of 104° or more in an aged patient generally points to a compli- 
cating infection. If the usual antipyretics do not reduce the 
temperature and there are pronounced cerebral symptoms, it 
may be necessar}^ to resort to the cold bath notwithstanding 
the danger of shock and collapse. The bath should be followed 
by friction and hot water bottles to the feet. For insomnia, 
urethane, veronal, sulphonal or trional can be used, and opium 
only if the other remedies fail to produce sleep. The carbamate 
group is rather safer and more reliable than the methane group. 
It is of the utmost importance to maintain the strength of the 
patient. This is accomplished partly by appropriate diet and 
partly by drugs. The drugs to be used for this purpose are 
small doses of strychnine, caffeine and carbonate of ammonia. 
Digitalis is always dangerous and strophanthus should be 
used only if the heart becomes weak and rapid. In a weak 
and slow heart spartein should be used in 1/2 -grain doses 
every three hours imtil there is response. Exhaustion of the 
heart is a constant danger and requires prompt treatment. 
When this sets in we must resort to hypodermic injections of 
strychnine, ether and camphor, and give internally, brandy 
and hot coffee. The head should be lowered and hot water 
bottles placed to the feet. 

The position of the patient should be occasionally changed 
to prevent hypostatic congestion. It is impossible to guard 
against intestinal hemorrhage or perforation, which sometimes 
occur in spite of every precaution. Absolute rest, giving 
the patient an opiate if necessary, is the only safe measure that 
can be suggested. Subcutaneous injections of a 2 per cent. 



39^ PATHOLOGICAL OLD AGE 

solution of gelatin have been tried in hemorrhage and success 
is reported. Ergot and adrenalin are extremely dangerous 
in the aged on account of their vasoconstrictor effect upon the 
whole circulatory apparatus, nevertheless, if the bleeding con- 
tinues, a hypodermic injection of 2 grains of ergotin and i 
grain of stypticin can be tried. High enemata of starch, 
gelatin and hemostatics have been suggested. When we 
remember that it is virtually impossible to get the clyster past 
the ileocecal valve and that the hemorrhage almost always 
comes from a typhoid ulcer in the ileum the uselessness of 
attempting local medication by way of the rectum must be 
apparent. A more rational treatment of intestinal hemorrhage 
would be by means of the metallic astringents, zinc or copper 
sulphate given by mouth, but while the hemorrhage may be 
controlled, the danger is from shock and exhaustion which 
may follow the loss of even a very slight quantity of blood. 
There is also a danger from the irritation of these salts upon the 
ulcers. There is no known method of combating perforation. 
Abdominal section has been recommended but no cure has been 
recorded. Other complications require the ordinary treatment 
for such. Bedsores can be avoided if the skin is kept dry and 
the pressure points are protected. The care of the typhoid 
fever patient is more important than drug treatment and the 
diet alone may change the entire aspect of the disease. In the 
selection of food, two factors must be considered, to maintain 
strength and to prevent irritating matter from reaching the 
intestinal lesions. The latter factor presents peculiar difficulties 
as it is hardly possible to arrange a dietary which will not 
contain refuse matter, or matter liable to undergo fermentation 
or decomposition in the bowel. The safest food is fresh milk, 
but the amount necessary to support the strength of an aged 
person, three to four pints daily, imposes excessive work upon 
the circulatory system. To avoid the excessive quantity of 
fluid, the condensed or evaporated milk should be used. If 
the milk diet becomes objectionable, its taste can be masked 
by the addition of salt, coffee or chocolate, or one of the prepared 
foods may be substituted temporarily or added. The foods 
containing a large percentage of alcohol should be avoided and 
likewise foods consisting principally of unconverted starch 
and those containing a large amount of lime. During the first 



TYPHOID FEVER ; 399 

week, while assimilation is good, we can use concentrated foods, 
etc. After the first week, or if assimilation is poor and undigested 
food particles appear in the feces, the food should be partially 
converted or predigested. The present-day tendency is to 
permit greater latitude in the variety of foods, but if the pre- 
viously recommended food substances can be taken, there will 
be less danger of intestinal irritation. There are numerous 
simple articles of food, such as thin barley gruel, albumin 
water, malt extract and gelatin, which are unobjectionable 
and which may be occasionally given, but they contain com- 
paratively little nutritive value. When there is extreme 
exhaustion and distaste for food, only the most concentrated 
foods should be used. Coffee may be given throughout the 
disease. Solid food should not be permitted until at least 
ten days after the temperature has become normal. Other 
hygienic measures, as fresh air, sunshine, rest, quiet, the avoid- 
ance of motion except the occasional shifting from side to side 
to prevent hypostatic congestion, are self-evident. The patient 
should not be permitted to exert himself, to arise, move, turn, 
talk much, etc. A bed pan which will slide easily under the 
body, must be used. 

The mouth, tongue, teeth and Hps should be regularly 
cleansed with an alkaline antiseptic solution, preferably one 
containing formaldehyde, or one of a solution of peroxide of 
hydrogen or permanganate of potash. It is almost unnecessary 
to caution the attendants about the thorough disinfection of the 
discharges, fecal, ininary and salivary, the bed pan and cuspidor, 
the clothing and bedding and everything that had been used 
about the patient. The physician himself is frequently the 
carrier of the infection and this he can avoid only if he will change 
his clothes before seeing the next patient and disinfect the 
exposed ones. The recently introduced antityphoid serum is 
apparently a reliable prophylactic. 

Paratyphoid fever presents apparently no marked differ- 
ences between that of mattuity and that of senility. The few 
cases reported give symptoms resembling a mild typhoid and 
in most cases bacteriological or Widal reaction tests are required 
to determine the diagnosis. The disease is treated as is typhoid 
fever. 

Typhus fever is relatively more frequent and more fatal in 



400 PATHOLOGICAL OLD AGE 

the aged than in maturity. It is, however, rarely met with in 
the United States and then almost exclusively in recent immi- 
grants coming from countries in which it is endemic. In the 
aged the period of incubation is prolonged, the disease develops 
slowly and the characteristic eruption may not appear until 
the tenth day or later. There is, however, the sudden onset 
with a pronounced chill followed by a fever which may reach 
104° on the third or fourth day. The temperature is irregular, 
remittent, or continuously high. The pulse is rapid and weak. 
Cerebral disturbances occur early and delirium, with subsultus 
tendinum and coma, may appear during the first week. The 
initial eruption of red macules soon shows a dark hemorrhagic 
center. In some cases the eruption begins with petechias, in 
others the macules almost immediately become hemorrhagic. 
These are rapidly fatal cases. There is extreme prostration 
from the onset of the disease and the functional activity of all 
the organs is impaired. Sordes and other typhoid symptoms 
appear earlier and are graver than in typhoid fever and the 
same complications that may occur in typhoid may also occur 
in typhus. Hypostatic congestion is one of the most frequent 
ones and is fatal. The early diagnosis of typhus fever is 
difficult, as typhoid fever, cerebrospinal meningitis, relapsing 
fever, smallpox, measles, sepsis and pneumonia may all begin 
with a chill, high fever and prostration, following a period of 
malaise. Relapsing fever can be excluded from consideration 
as it does not occur in the United States and has a specific 
spirocheta in the blood which is recognizable from the onset of 
the disease. Measles presents neither the distinct chill, high 
fever nor prostration of typhus. The pain and contractions 
of the spinal muscles occurring in cerebrospinal meningitis are 
absent in typhus. In variola the eruption begins as discrete 
papules on the forehead and wrists and there is a fall in the 
temperature and clearing of the mind as soon as they appear. 
Before the appearance of the eruption there is no diagnostic 
sign by which the two can be differentiated although the prostra- 
tion is not so severe in smallpox nor is the mind dulled. In 
hemorrhagic variola the initial symptoms may be fully as 
severe as in typhus, but the eruption is vesicular and there is 
also an eruption upon the fauces. In pneumonia the cough and 
physical signs may be detected on the second day. The pres- 



i \i 



INFLUENZA 4OI 

ence of the pneumococci will establish the diagnosis. Typhoid 
fever may give the same severe initial symptoms as typhus, or 
the latter disease may give mild initial symptoms. In either 
case no definite diagnosis can be made until the appearance of 
the rash, which in typhus may be seen on the fourth or fifth 
day, though in the aged it appears later, and the bacteriological 
finding of the typhoid bacillus. In sepsis an early diagnosis 
can usually be made by the presence of the pyogenic germs. 
In most contagious diseases the existence of an epidemic sim- 
plifies the diagnosis. 

Treatment is piu'ely symptomatic and demands, primarily, 
the support of the patient's strength. There being no specific 
intestinal lesions as in typhoid fever, greater latitude is permitted 
in the selection of food, which should be as concentrated as 
possible, and any indication of intestinal disorder, as evidenced 
by sour or foul-smelling stools, or the presence of particles of 
undigested food, should be met by a thorough catharsis, fol- 
lowed by an intestinal antiseptic, and a milk or predigested food 
diet. The medicinal treatment is the same as in typhoid fever. 

Influenza occurs rather frequently, the advantage of greater 
resistance being more than counterbalanced by the presence of 
chronic bronchitis, the impaired mucous membrane forming a 
fertile field for the propagation of the pathogenic bacilli. The 
disease in the aged is usually of a toxemic respiratory type, 
rarely the nervous form, still more rarely the gastrointestinal 
type. There are rarely typical cases of any of these forms of 
the disease, most cases presenting symptoms of all types, the 
toxemic and respiratory symptoms predominating. There are 
no marked differences in the symptoms between maturity and 
senility. The temperature is usually low, rarely over 102°, 
frequently it ranges between normal and 100°. Owing to the 
atrophy of the nasal mucous membrane the rhinitis may be 
absent but conjunctivitis may be marked. The disease begins 
with the usual mild chills followed by elevation of temperature, 
headache, pains in the extremities and back. A pharyngitis 
is noted, followed by a laryngitis, the catarrhal inflammation 
proceeding downward into the trachea and bronchi. Facial 
herpes occurs frequently and the face is usually flushed, some- 
times in patches. The disease itself is not grave, but the 
frequency of pulmonary complications, especially lobtdar pneu- 
26 



402 PATHOLOGICAL OLD AGE 

monia and pleurisy, makes it one of the more serious diseases of 
old age. Owing to the mildness of the initial symptoms of the 
bronchopneumonia, that complication is frequently overiooked 
until near the fatal end. (See Senile Pneumonia.) The earliest 
symptom of bronchopneumonia is usually an irregular rise and 
fall of the temperature, but this may not be noticed unless the 
temperature is taken every two hours after the first rise is noted. 
Circulatory disturbances, evidenced by weak cardiac impulse, 
weak pulse, arrhythmia, dyspnea and cyanosis, occur frequently, 
especially during the period of convalescence. Cerebral and 
nervous complications are infrequent with the exception of 
trigeminal neuralgia. Some cases of lobular pneumonia appear 
without the initial coryza, and laryngitis, and the diagnosis 
can be made only by finding the influenza bacillus, and cases 
have been reported giving cerebral symptoms alone but showing 
the bacilli in the cerebrospinal fluid. 

A positive diagnosis can be made only when the pathogenic 
germs are found. In the absence of these findings, the disease 
may be mistaken for a simple cold, although in the latter attack 
the acute invasion, prostration, neuralgia and herpes are absent 
or mild. The coryza, and early bronchitis will distinguish it 
from meningitis, tuberculosis and typhoid. 

Ortner describes under the name chronic influenza a type 
which is protracted or recurrent and where the bacilli can be 
found for a long period in the sputum and nasal secretion. It 
occiirs in aged emphysematous individuals, either following an 
acute attack, or coming on with mild symptoms of malaise and 
coryza. The symptoms may persist for months and the bacilli 
are found for a long time after all symptoms have disappeared. 

The treatment of influenza is symptomatic and hygienic. 
French physicians use colloidal metals by inunction or by sub- 
cutaneous or intravenous injection as curative agents in infec- 
tious diseases generally, but this mode of treatment is still 
experimental. For the relief of symptoms the measures useful 
in earlier life can be employed, with due regard, however, for 
the degenerated state of the tissues. Antipyretics are rarely 
required. For the neuralgia, distressing cough without expec- 
toration, or with scanty tenaceous mucus, for insomnia, dyspnea, 
etc., the same treatment is required as in simple neuralgia, 
bronchitis, cardiac asthma, etc. 



ACUTE ENDOCARDITIS 403 

ACUTE ENDOCARDITIS 

Etiology. — Contrary to the generally accepted view that 
acute endocarditis is probably of bacterial origin in all cases, we 
find that but few cases occurring in eld age follow a bacterial 
disease, while even in younger life endocarditis has been found 
in most cases of fatal chorea. We must either assume that such 
diseases of the fourth group as diabetes, gout, cancer and 
chronic nephritis during which valvular disease frequently 
develops, are bacterial, or else we must drop the assumption 
that acute endocarditis is always of bacterial origin. 

Acute endocarditis is due to inflammation of the endocar- 
dium produced b^^ some irritating constituent of the blood. 
This may be bacteria or bacterial or other toxins, or else the 
abnormal constituents found in the blood in diabetes, gout, ne- 
phritis, etc. The bacterial endocarditis is rare in the aged as 
bacterial diseases producing endocarditis are infrequent at that 
time of life. The simple non-bacterial form is rarely recognized, 
the assumption of its existence being usually based upon the 
production of a valvular lesion in the course of the causative 
disease. 

Pathology. — In the bacterial form there is a deposit of 
fibrin in which leucocytes and blood plates are imbedded upon 
the valves or less frequently upon the cordae tendinae or other 
parts upon which the blood impinges. This is followed by a 
proliferation of endothelium and sub endothelial connective 
tissue into this deposit, the whole forming the so-called "vege- 
tations," fringes or warty excrescences from 1/30 to 1/4 inch 
in thickness, continuous with the adjacent tissue. In rare 
cases the vegetation is attached to the base by a pedicle. These 
vegetations interfere with the free action of the valves, some- 
times they contract, producing marked valvular deformity. 
During the continuation of the disease the vegetations are 
covered with a layer of fibrin which affords a lodgment for 
pyogenic bacteria and if an invasion of such bacteria takes 
place the disease becomes an ulcerative or malignant endo- 
carditis. In this case the vegetations may soften, ulcerate and 
suppurate, necrosed tissue is thrown off and carried in the 
blood current as emboli, usually plugging some vessel in the 
brain, liver, spleen, kidneys or other organ. This latter con- 



404 PATHOLOGICAL OLD AGE 

dition is, however, extremely rare in the aged, as the aged in- 
variably succumb within a few days after the septic infection. 
Fragments from non-septic vegetations may be torn off and 
cause emboli and infarctions in distant parts. 

In the non-bacterial endocarditis there is a thickening of the 
endothelium with deposit of fibrin, but no organization into 
vegetations. The action of the valves is, however, always in- 
terfered with. In most cases occurring in the aged there are 
at the same time senile changes in the endocardium (see Senile 
Endocarditis) and only the presence of the fibrin deposits 
distinguishes the acute inflammatory condition from the non- 
inflammatory senile degeneration. 

Symptoms. — In the non-bacterial variety of acute endocar- 
ditis, before the valvular lesions give their distinctive symp- 
toms, the only symptom that might attract attention is irregu- 
lar heart action. Even this usually escapes notice until the 
valvular murmur appears. When the irregular heart action 
is so marked as to be noticeable it is usually attributed either 
to the causative disease or else to the senile changes in the 
heart. There is no pain or elevation of temperature connected 
with this variety of endocarditis. 

In the bacterial variety the earliest symptom is a rise in 
temperature not due to any apparent change in the character of 
the causative disease. The rise may be two or three degrees. 
About the same time the heart action becomes accelerated and 
irregular, there is a feeling of discomfort about the heart and 
the circulation is disturbed. These symptoms, which are 
usually mild, are followed by symptoms of valvular incom- 
petency, occasionally stenosis, the mitral valve being usually 
first involved. The later symptoms are those of the valvular 
lesion. In the malignant or ulcerative form of acute endocar- 
ditis there is a sudden rise in temperature of two or three or 
more degrees, marked mental and physical depression, sweating, 
irregular heart action rapidly followed by the valvular lesion 
and its symptoms. In the aged death usually occurs in a few 
days without the occurrence of embolism, the most frequent 
complication in younger individuals. There are several types 
of this variety of endocarditis, typhoid, septic, meningeal and 
a type in which the cardiac and circulatory disturbances are 
most prominent. The rare cases that occur in the aged present 




Lung, Chronic Interstitial Pneumonia, Bronchiectasis, 
Hyaloserositis, and a Terminal Catarrhal Pneumonia Re- 
sulting from Concurrent Infection by the Tubercle Bacil- 
lus and Pneumococcus. (From Coplin's " Manual of Pathol- 
ogy.") A, A. Greatly thickened pleura. B. Dilated bron- 
chi. C. One of many strata of fibrous tissue irregularly 
transversing the organ. D. Large caseous lymph-node near 
hilum of lung, and immediately adjacent to the aorta, a 
section of which is shown just above. The aorta is the 
seat of slight atheroma. 



INFECTIOUS PNEUMONIA 405 

typhoid symptoms. These cases are invariably fatal. The 
non-malignant forms in the aged become chronic and follow 
the course of senile endocarditis. 

Treatment. — No form of treatment has been of the slightest 
avail in the malignant form of the disease. For other forms 
rest is of the utmost importance. Cloths wrung out in cold 
water and placed over the heart will relieve temporarily the 
irregularity and the feeHng of discomfort in the organ. As 
long as the underlying cause persists the irritation and inflam- 
mation will persist and continue to do irrepairable damage. 
The further treatment is such as has been indicated under 
senile endocarditis and the valvular disease that had been 
produced. Various drugs have been recommended, such as the 
iodides to promote absorption of the lymph, mercury in various 
forms to prevent the deposit of fibrin, alkalies to increase the 
alkaHnity of the blood, aconite and veratrum to weaken the 
force of the heart, etc. They are rarely given in time to be 
effective. ^ 

INFECTIOUS PNEUMONIA 

It has already been stated in the chapter on senile pneu- 
monia that faulty nomenclature and other causes have pro- 
duced confusion in the conception of the various pathological 
states included under the term "pneumonia." In this work 
all pulmonary inflammations are divided into two classes, in- 
fectious and non-infectious pneumonias. In the non-infectious 
class are placed inflammations due to irritation, extension of 
non-infectious inflammations, and secondary inflammations 
not due to pathogenic germs. In the infectious class are in- 
cluded those inflammations which are caused by pathogenic 
germs. 

Etiology. — The most frequent cause of infectious pneumonia 
is activity of Frankel's pneumococcus. Other germs that are 
known to cause pulmonary inflammation are the Friedlander 
bacillus, streptococcus, staphylococcus, micrococcus catar- 
rhalis, the diphtheria, influenza, typhoid and colon bacilli and 
the meningococcus. It is believed that other germs are also 
able to cause the disease, as it occurs occasionally in the course 
of measles, whooping cough, typhus, variola and other presum- 



4o6 PATHOLOGICAL OLD AGE 

ably germ diseases. The senile organism is more resistant to 
germ activity than the organism in earlier life, but the resisting 
power may be lowered through general debility. In most cases a 
fertile field is prepared by a previous disease or by a momentary 
perversion, as, for example, when inhaling cold air, a tempo- 
rary hyperemia is produced in order to raise the air to the body 
temperature, this hyperemic surface becoming a suitable field 
for germ development. Local traumas leave points of exposure 
for the entrance of the pathogenic germs, while the shock of 
traumas generally reduces the vitality of the body and lowers 
its resisting power to germ development. The irritation pro- 
duced by the inhalation of dust or noxious vapors causes local 
hyperemia, or a catarrhal condition which favors the bacterial 
activity upon which the disease depends. Passive hyperemia, 
bronchitis, pneumokoniosis, and interstitial pneumonia, all 
supply suitable fields for the propagation of the germs. While 
the germs generally reach their field by inhalation they may 
reach their localization in the lungs through the lymph and 
blood channels. 

A pure pneumococcus infection is rare in old age and there- 
fore a classical acute lobar pneumonia is infrequent. It is 
almost always a mixed infection in which the pneumococci and 
streptococci predominate. In many cases no pneumococci are 
found, and in cases where pneumonia occurs as a complication of 
another infectious disease the germs of the primary disease pre- 
dominate, or are alone. Most cases in the senile are secondary. 

Pathology. — The classical stages of acute lobar pneumonia 
are rarely found in the aged. The disease may be localized or 
diffused. Upon section diiring consolidation, the surface ap- 
pears dark red, smooth and moist, exuding a bloody serum. 
Gray hepatization is very rare, the patient seldom surviving the 
stage of red hepatization, and where recovery does take place, 
resolution begins during this stage. In diffused pneumonia, 
hyperemic areas are scattered throughout the lungs, frequently 
in the upper lobes or in the upper part of the lower lobes. The 
microscopic appearance depends mainly upon the type of the 
predominating germs. In cases where the pneumococci pre- 
dominate, the alveoli are filled with a fibrinous exudate. The 
influenza bacilli cause greater destruction of the epithelial cells, 
and their debris may completely fill the alveoli. If pyogenic 



INFECTIOUS PNEUMONIA 407 

germs are present, pus cells will be found. In most senile cases 
the alveoli contain principally serum and broken-down epithe- 
lial cells, some fibrin, red blood cells, leucocytes and occasion- 
ally pus cells. The capillaries are swollen and engorged. In- 
cidental pulmonary lesions such as caseous degeneration due to 
tuberculosis, abscess and gangrene due to pyogenic bacteria, 
interstitial edema, etc., are found occasionally. 

Symptoms. — The usual sudden onset of acute lobar pneu- 
monia, with a chill followed by high fever, is infrequent in the 
aged. When this does occur there is almost always a profound 
pneumococcic infection, with rapid prostration, and a fever 
ranging from 102° to 104°. Within a day or two there is a 
distressing cough, and some time later blood-streaked expectora- 
tion appears. The sputum is scanty and tenaceous; in some 
cases, however, it is entirely absent. Many senile patients will 
swallow the expectoration imless watched. Pain is usually 
slight. In this form of infectious pneumonia the disease is 
grave from the onset, and prostration is rapid, the breathing is 
shallow and rapid, but not panting as in younger persons; 
dyspnea is not marked, but cyanosis sets in early and cerebral 
symptoms are pronounced. The heart at the onset acts with 
increased force and rapidity, but it soon becomes weak and grows 
weaker as the prostration increases. Delirium sets in early. 
There is usually constipation, the urine is diminished and 
albuminous and may contain casts. The amount of urea is 
diminished. In acute lobar pneumonia in the aged, death may 
occur during the first or second day, and is rarely delayed 
beyond the eighth day. If improvement does take place the 
fever gradually subsides, the expectoration becomes more pro- 
fuse and the mind becomes brighter. The face, which has 
usually a dark flush over the malars, resumes its normal appear- 
ance. Recovery is by lysis. A sudden drop in temperature 
occurs before dissolution, while a copious watery expectoration, 
with increasing dyspnea, indicates pulmonary edema. 

In most cases of infectious pneumonia in the aged the dis- 
ease develops rapidly but not suddenly. Where it occurs sec- 
ondarily to another disease, the symptoms of the primary dis- 
ease are aggravated, there is besides a rapid rise in temperature, 
dyspnea, and rapid shallow breathing, followed by cough and 
expectoration, which after a day or two becomes blood-streaked 



408 PATHOLOGICAL OLD AGE 

and may be ptirulent. In some cases the system had been so 
weakened that the patient is unable to cough while the mind 
may be too impaired to realize the import of the local irritation 
produced by the secretion in the vesicles and tubes. In such 
cases cough and expectoration will be absent, but the increas- 
ing amount of secretion will lessen the aerating surface, the 
dyspnea will increase, cyanosis sets in and the respiration 
becomes more rapid. In every case of pneumonia, whether 
infectious or non-infectious, primary or secondary, localized 
or diffused, there is rapid prostration, loss of appetite and 
mental depression. There is generally some pain when cough- 
ing or when taking a deep inspiration. If the disease is local- 
ized, the pain is located in the affected part, but where there 
are scattered areas of consolidation, the pain on inspiration is 
most severe where the affected part of the lung in expanding 
rubs against the pleiira, — while the pain on coughing is most 
severe in those areas in which the consolidation has been most 
complete, i.e., in the parts first involved. There may also be 
pleuritic pain on coughing. Pain is not felt when cerebral 
symptoms appear. A pneumonia following a hemorrhagic 
infarct of the lung presents a blood-stained watery expectora- 
tion, but this condition is seldom found in the aged. The 
physical signs depend upon the type. There is dulness upon 
percussion over the affected site,|but this dulness may be com- 
pletely masked by an area of emphysema over the consolida- 
tion. In the localized type, dulness at the base points to a 
hypostatic pneumonia which may be infectious or non-infec- 
tious. The usual sites of a localized pneumonia in the aged 
are the apex or base of the upper lobe, the apex of the lower 
lobe or the side of the upper or middle lobe. The dulness is 
then found either in the supraclavicular space, or in the inter- 
scapular space, or below the axilla. In the diffuse type, small 
areas of dulness may be found over all parts of the lung. An 
important sign, both of the disease and its locality, is that of 
crepitation, heard at the end of inspiration and at the begin- 
ning of expiration. Owing to the senile anatomical changes 
in the chest wall, we do not find any difference in expansion and 
owing to the frequent presence of an old bronchitis r^les may 
be heard in all parts of the chest. 

When resolution sets in the symptoms abate, but in the 



INFECTIOUS PNEUMONIA 409 

diffuse type new foci of infection may occur, while old areas 
of consolidation clear up, and thus we may get an irregular 
temperature with remissions and intermissions; periods of 
improvement with relapses, and with changing areas of infec- 
tion. The pneumonia may be then prolonged for several weeks, 
the system becoming constantly weaker and the patient finally 
succumbing from general exhaustion, cardiac exhaustion or 
pulmonary edema. Dtuing the initial fever the heart action 
is more powerful than normal, but it rapidly weakens, partly 
as a reaction from the excessive activity, partly through im- 
paired pulmonary circulation (the right heart being weakened 
and dilated), and partly through the toxemia which alters 
the circulating medium and interferes with the vasomotor 
regulation. These circulatory changes cause passive conges- 
tion of the liver, spleen and kidneys, with consequent impairment 
of their fimctions. The urine is diminished in quantity, the 
amount of urea and chlorides is lessened, while albumin, casts, 
an excess of uric acid and red and white blood cells are usually 
present. When resolution sets in the iirine becomes normal 
imless a nephritis had developed. The most prominent and 
most serious indication of hepatic distiurbance is icterus. 

The blood in infections pneumonia shows a leucocytosis, 
with increase in fibrin. When resolution sets in a proteolytic 
ferment appears in the blood. Nervous and cerebral symptoms 
usually appear early such as headaches, insomnia, later delirium 
and finally coma, diminished reflexes, neuritis, etc. 

Pneumonia is the most fatal disease of the aged. This is 
partly due to the fact that the onset is usually so mild that the 
disease is far advanced before it is recognized. It is only in the 
forms that are rare in old age, such as acute lobar pneumonia 
and general pneumococcic infection that pronounced symptoms 
appear from the onset of the disease, and these forms are 
usually virulent and fatal. It is the most frequent of all com- 
plications and the hypostatic form is a constant menace in every 
case in which a patient is confined to his bed. In many cases 
the physical signs can be foimd before there are any suggestive 
symptoms and it is therefore necessary frequently to percuss 
the back of the chest in order to determine any foci of dulness 
present. In some cases, where the only suggestive symptom of 
pneumonia is rapid prostration, we can get a history of exposure 



4IO PATHOLOGICAL OLD AGE 

which may show the inhalation of cold or rarified air or of 
noxious vapors; or the patient may remember that a bit of 
food went "in the wrong way," thereby producing a deglutition 
pneumonia. More often there is a history of another disease 
or traumatism and the examination of the chest will explain why 
the symptoms suddenly became aggravated. Cases may re- 
cover when seen early, but where pneumococci predominate, 
or if the disease is secondary to typhoid fever, death is almost 
inevitable. While the prognosis is unfavorable in every case 
of pneumonia, whether infectious or non-infectious, there are 
cases offering a fair chance for recovery. These are the inhala- 
tion pneumonias and those pneumonias that are due to other 
germs than the pneumococci. Rapid prostration diminishes 
the chances for recovery. Puriilent or mucopurulent expectora- 
tion indicates the presence of pyogenic germs which may cause 
abscess or gangrene of the lung. The only diseases that may 
be mistaken for pneumonia are pleurisy, bronchitis, tuberculosis 
and typhoid fever. In early pleurisy there is absence of per- 
cussion dulness, and of rapid shallow respiration; there are 
friction sounds, but no rMes. In pleurisy with effusion, the 
change in the level of percussion dulness upon change in position 
will distinguish it from the graver disease. In bronchitis there 
are no areas of dulness, and there is generally a history of previ- 
ous cough and expectoration, the expectoration being thinner 
and more profuse than that of pneumonia. There is no prostra- 
tion or pain. Tuberculosis is slow in its progress and the 
sputum contains the pathogenic bacilli. If there is any doubt 
about the differential diagnosis, it can be cleared up by the 
microscope and by the tuberculin test. The differentiation 
between typhoid fever and pneumonia depends upon the 
bacteriological examination of the sputum, blood and feces, 
and upon the Widal test. 

Treatment. — The treatment of infectious pneumonia follows, 
in the main, the lines laid down for the treatment of senile 
pneumonia. In addition to these measures, which are intended 
to relieve symptoms and prevent the most frequent causes of 
death, serum therapy should be employed. Infectious pneu- 
monia in the aged is almost always a mixed infection and the 
antipneumococcic serum has little effect upon it. Serum 
therapy is worse than useless if it is not based upon a bacterio- 



TUBERCULOSIS 4II 

logical examination. In all cases in which the symptoms may- 
be ascribed to two or more forms of bacteria it is necessary to 
make such examinations before using any serum, vaccine, 
bacterin or any other bacterial product. There are various 
combinations of sera and vaccines on the market and the 
selection of the appropriate combination depends upon the 
bacteriological examination of the expectoration, or of the blood. 
Wherever possible, an autogenous vaccine should be used in 
preference to stock vaccines. 

Some incidental symptoms may occur in infectious pneumonia 
that do not occur in the non-infectious senile form. For the 
fever we can use quinine or tepid sponging, never the coal-tar 
products or cold baths. Creosote is of service if the cough is 
distressing. The pernicious practice of giving narcotics is 
probably responsible for many deaths in pneumonia, by further 
weakening the respiratory centers, and by allaying the irritation 
caused by the mucus, which is so necessary to arouse the reflex 
action of coughing for the removal of the secretion. If the 
expectoration is thin, yet the patient cannot bring it up, senega 
should be given, but if there is a scanty tenaceous expectora- 
tion, muriate of ammonia should be employed. 

The hygienic measures are the same as those of senile 
pneumonia. 



TUBERCULOSIS 

Tuberculosis in the form of fibroid phthisis occurs more 
frequently in old age than in earlier life. The disease is rarely 
a primary infection in the aged, being in almost every case a 
recrudescence of a disease that had been apparently arrested 
years before. It is possible that in some cases the infection 
has occurred at a time when the body was able to resist its 
pernicious activity and that in the course of years the resistance 
was lowered and the latent bacilli became active, or that late 
in life the virulence of the germs had increased. The acute or 
general tuberculosis is rare in advanced life and, while local 
infection may occur almost anywhere just as in younger indi- 
viduals, the usual location is in the lungs where it produces a 
fibroid degeneration. 



412 PATHOLOGICAL OLD AGE 

Fibroid Phthisis 

This is the usual form in which tuberculosis appears in the 
aged. The disease is slowly progressive and may exist for 
years before the symptoms are sufficiently severe to cause the 
patient to seek medical aid, or before a particle of blood-streaked 
sputum attracts his attention. The typical symptoms, as they 
appear in pulmonary tuberculosis in early life, do not occtu* in 
the aged. The temperature is normal. There are no night 
sweats, no rapid emaciation, rarely secondary tuberculous 
diseases. There is, however, dyspnea, cardiac palpitation or 
arrhythmia, and the face becomes dusky or cyanotic; but these 
symptoms are usually attributed to the heart and impaired circu- 
lation. There is usually a cough, and the expectoration may be 
profuse or scanty. In some cases there is little cough or expec- 
toration, the slight coughing being due to the irritation pro- 
duced by a secretion of mucus of atrophic bronchitis. The 
expectoration is occasionally blood-stained, especially after 
severe attacks of coughing. Pulmonary hemorrhage, in which a 
quantity of blood is lost, may be due to erosion of a blood-vessel, 
to excessive or sudden strain or to a sudden rise in blood pres- 
sure, and cases have been reported in which there was a rupture 
of a varicose vein in the trachea and rupture of a vessel in a 
bronchus while straining at stool. A profuse hemorrhage is fatal. 

Late symptoms are cachexia and emaciation, persistent 
dyspnea, cough and expectoration, the latter purulent or muco- 
purulent and occasionally blood-streaked and a sinking of the 
chest walls over the diseased part of the lungs. The supra- 
clavicular and infraclavicular spaces are deeply depressed, 
most markedly so on the affected side. While the respiratory 
movements in old age produce a rise and fall of the rigid chest 
walls instead of an expansive movement, there may be noticed 
during inspiration a retraction of the intercostal spaces on the 
affected side and a bulging on the unaffected side. If both 
sides are affected the intercostal spaces of both will be retracted. 
Percussion gives dulness over the affected area, the percussion 
sound during deep inspiration being shorter, and almost fiat. 
There are, however, many sources of error in percussing a senile 
chest with fibrous phthisis. Pneumokoniosis, senile emphy- 
sema, the atrophied lung, pleuritic adhesions, areas of hyper- 
emia, and old cavities, all tend to modify the percussion note. 



FIBROID PHTHISIS 413 

The auscultatory signs are often difficult to interpret as there 
may be all varieties of rales and breathing, friction sounds and 
murmurs. Expiration is usually prolonged and a tuberculous 
click can often be heard over a cavity. It resembles a single 
coarse bubbling rMe but is louder and deeper and is often felt 
by the patient. It is pathognomonic of a cavity. The char- 
acter of the rMes depends upon the character of the bronchial 
catarrh, this condition being almost always present, but other 
pathological rale-producing conditions may also exist, which 
give no other symptom than these rales. Radiography gives 
valuable information, light areas indicating cavities, dark areas 
indicating consolidation, induration or growths. In all cases 
the finding of the bacilli in the sputum establishes the diagnosis, 
although they may be absent at one examination and present at 
the next. The various tuberculin tests can be used, but a 
positive reaction may be due to a former cured disease. There 
are frequent complications arising from extension of the tuber- 
cular process. Hoarseness and dysphagia are generally due to 
laryngeal tuberculosis, pain may be due to irritation of the 
pleura, to pressure upon a nerve or to a neuritis. There is occa- 
sionally a tubercular pericarditis, rarely with effusion, and 
tubercular ulcers of the intestines may occur especially in those 
who swallow the sputum instead of expectorating it. Liver and 
spleen are occasionally enlarged when the circulation is impaired 
and passive congestions result in the viscera. The presence of 
the bacilli is the only distinctive feature by which this disease 
can be distinguished from fibrous pneumonia. 

In the treatment of fibroid phthisis in the aged the same 
general hygienic measures must be adopted as in younger indi- 
viduals. Fresh dust-free air and sunshine are of the greatest 
importance. The dietary requires careful study as the senile 
digestive organs act more slowly and are often perverted, and 
the diet applicable to the young may be wholly inappropriate 
for the aged. The milk and egg diet useful in younger individuals 
soon becomes objectionable, and the amount of fluid that must 
be taken imposes excessive work upon the circulatory apparatus 
and kidneys. The food should be easily digestible, as concen- 
trated as possible, and leave little waste. This excludes food 
containing a large amount of cellulose, fruits, jellies, foods fried 
in fat, and food that must be swallowed in lumps. The cereals 



414 PATHOLOGICAL OLD AGE 

and leguminous vegetables should form the bulk of the food. 
Meats, if given at all, should be well cooked, and if the teeth 
are too defective for mastication it should be omitted altogether 
or meat juice should be substituted. Persons accustomed to 
alcoholic drinks need not be deprived of them, but the distilled 
liquors and wines should be diluted. If the sputum becomes 
blood-streaked alcoholics must be omitted. 

Sanitarium and health . resort treatment is rarely required. 
High altitudes are dangerous for aged tuberculosis cases and a 
moist atmosphere is liable to raise the blood pressure and in- 
crease the tendency to hemorrhage. 

Medicinal treatment is indicated only for the relief of dis- 
tressing symptoms and for complications. Turpentine, guaiacol 
and eucalyptol may be used by inhalation if there is an irritat- 
ing cough with scanty, tenaceous secretion, or if the mucus has 
a fetid odor. Guaiacol and creosote should not be given by 
the stomach as they soon produce anorexia and may cause 
gastritis. They are to be used by the inhalation method which 
is more direct and more effectual. Treatment by tuberculin 
has been often quite successful. If the cough is very distress- 
ing and prevents sleep dionin or heroin in 1/12- to i/8-grain 
doses can be given. Dyspnea is seldom severe enough to re- 
quire treatment unless occurring after excessive exercise. If 
it becomes necessary to give relief for this then the inhalation 
of 3 minims of amyl nitrite will give immediate results. For 
prolonged treatment the nitrite of soda in 1/6- to 1/2 -grain 
doses three times a day should be used. Intestinal disorders 
are always due to local conditions, generally to tubercular 
ulcers, sometimes to excessive or improper food, or to drugs. 
Constipation may be due to atonicity of the intestines or to 
drug action. If there is no obvious cause a mild laxative, such 
as castor oil, should be given and all food and drugs withheld 
for a day. If diarrhea continues there is a persisting local 
cause, probably an ulcer. In this case intestinal antiseptics, 
as salol, the sulphocarbolates, urotropin, etc. , should be used in 
combination with a mild astringent as bismuth subnitrate. The 
food should bepredigested, or partly digested, or food preparations 
which leave little or no waste should be used instead. Acids and 
acidulated drinks should be omitted, but buttermilk may be taken. 

Miliary or acute general tuberculosis is rare in the aged and 
when it does occur it is invariably fatal. The disease is always 



ACUTE GENERAL TUBERCULOSIS 415 

secondary to a local infection, but this may have been so mild 
as to have escaped detection. Miliary tuberculosis presents 
the constitutional symptoms of toxemia, but the local symp- 
toms, arising from the organs or tissues containing the tuber- 
culous lesions, predominate. These local symptoms are usually 
severe results of the primary infection. In some cases the con- 
stitutional symptoms, chills, fever, headache, prostration, etc., 
are severe from the onset, while the local manifestations are 
mild, and the patient passes rapidly into a typhoid state. There 
may be then a muttering delirium, insomnia, subsultus ten- 
dinum, picking at the bed clothes, dyspnea, cyanosis, a weak, 
rapid pulse but a low temperature, involuntary discharge of 
urine and feces and rapid emaciation. Death in these cases 
occurs during the first or second week. In the aged the disease 
usually assumes a toxemic pulmonary type in which the pul- 
monary symptoms predominate resembling acute lobar pneu- 
monia or a capillary bronchitis. The primary lesion in these 
cases is a fibroid phthisis which is often not recognized until the 
acute miliary tuberculosis has appeared. In rare cases the 
constitutional symptoms are mild, fever is absent, but there are 
symptoms of a secondary infection in other tissues, generally 
in the brain. In other cases the mild symptoms of a fibroid 
phthisis suddenly become severe, there is cyanosis, dyspnea, 
a hacking, painful cough, blood-streaked mucopurulent expec- 
toration, rapid emaciation and loss of strength and finally, 
death from exhaustion. In other forms of miliary tuberculosis, 
the cerebral symptoms predominate and the disease appears as 
a meningitis. In others again there is a toxemic pleuritic form 
and Ortner describes a marantic form which occurs in the aged. 
The predominating symptoms of this are a rapid loss of strength 
and waste of tissue without marked local or other constitutional 
manifestations. In rare cases there is an apparent improve- 
ment lasting for a day or two, possibly longer, with a fatal 
relapse. In determining the diagnosis the finding of the patho- 
genic bacillus is the most important factor. Diseases which 
resemble it clinically in its onset are influenza, sepsis, typhoid 
fever, pneumonia, bronchitis, meningitis, and actinomycosis. 
Where there is a history of tuberculosis the diagnosis is clear. 
In most cases a bacteriological test is necessary to determine 
the character of the infection, but an early diagnosis of miliary 
tuberculosis can often be made by the tuberculin test. 



41 6 PATHOLOGICAL OLD AGE 

Treatment. — There is nothing we can do except to relieve 
the symptoms and our efforts in this direction often fail. Nar- 
cotics and hypnotics can be used to relieve pain, insomnia and 
occasional delirium, and expectorants or stimulating inhalations 
to increase and liquefy scanty and tenaceous expectoration. 
There is nothing known that will retard the rapid emaciation 
and loss of strength. Stimulants are but of momentary utility, 
the exhaustion keeping pace with the emaciation. In diseases 
such as this, which in the present state of knowledge are classed 
as absolutely fatal, we are justified in making any experiment, 
however irrational it may appear, to prolong life. (This would 
even justify the implantation of the germs of an antagonistic 
disease if the latter offers a possibility of longer life than the 
original disease.) 

Bone tuberculosis is occasionally found in the aged, being 
carried over from earlier life either as the continuation of a 
slowly progressive tubercular process or as a recrudescence of 
the process after years of apparent cure. In the latter case the 
disease is usually active, rapid in its progress, there are many 
foci in the bones and organs, emaciation and debility proceed 
rapidly and the patient succumbs in a few weeks or months. 
In the slowly progressive form the disease may appear in the 
bony structure secondary to visceral tuberculosis or it may be 
the continuation of an original bone tuberculosis, usually a 
Pott's disease. The secondary disease usually attacks the foot, 
knee, hip, wrist or elbow. Tuberculosis in these locations is 
frequently mistaken for rheumatic arthritis or chronic rheuma- 
tism, occasionally for syphilis, osteomyelitis, rarely for sarcoma. 
The diagnosis should not be difficult if we remember that tuber- 
culosis and syphilis give histories pointing to these diseases, that 
rheumatic arthritis produces characteristic deformities, that the 
tubercular joint is always swollen, blanched and has painful 
points. The pain is, however, never as severe as in osteomyelitis. 
The history alone will usually suffice to determine the diagnosis, 
but to clear up all doubts the tuberculin test may be necessary. 

Pott's disease is usually carried over from maturity. When 
originating in advanced age its progress is rapid, there is con- 
siderable pain, the normal spinal curve becomes altered, a dis- 
tinct bend being found at the site of the bone lesion ; occasionally 
there is abscess formation, and there is marked cachexia. A 
neural form of vertebral tuberculosis is described in which the 




Femur, head and neck; beginning tuberculosis. 
A. Small area of caseation in epiphysis just under 
articular cartilage, called subchondral. B, B. Same 
in epiphyses at point of junction with shaft; intraos- 
seous, C. Subperiosteal. {After McArdle {redrawn) 
*^ Trans. Royal Acad, of Med. in Ireland" vol. vii, 
1889, p. 140.) 



CEREBROSPINAL MENINGITIS 417 

only symptoms are those of myelitis and neuritis. The diagnosis 
must be made by excluding the various forms of spinal sclerosis 
and other diseases giving localized spinal pain. Pic says radio- 
graphy performs a great service in diagnosing this form of Pott's 
disease. There is also a latent form of vertebral tuberculosis which 
gives no marked symptoms, but the lesion is found after death. 

The treatment of bone tuberculosis in the aged is the same as 
in younger individuals. 

Relapsing fever does not occur in the United States and is infre- 
quent in the aged even in countries where it is met with. Accord- 
ing to Ortner it does not differ from the disease as it occurs in 
earlier Hfe, except that it is more fatal in the old owing to the 
grave secondary complications, pulmonary disease, suppurative 
parotitis and cardiac exhaustion. Experimental treatment 
with an antispirochetic serum has been reported favorably. 

Miliary fever and Malta fever do not occur in United States 
and are rare in the aged in countries where they are epidemic. 

Cerebrospinal meningitis is rare in old age, only i per cent. 
of the cases reported in the last New York epidemic occurring 
in persons over 50 years of age. The disease presents some 
minor differences in symptomatology from the disease in younger 
individuals. It begins usually with slight chills, the temperature 
is but little higher than normal, and in some cases may be 
normal or subnormal. The pain in the lumbar regions appears 
early, is intense, and proceeds rapidly upward along the spine. 
The rigidity of the muscles of the neck usually appears on the 
first day and prevents forward and backward motion, but 
lateral motion may not be impaired for several days. Opis- 
thotonus is rare. The cerebral symptoms are severe from the 
onset of the disease. These are intense headache, photophobia, 
unequal dilatation of the pupils, impairment of the motor 
oculi, perhaps strabismus, nystagmus or ptosis, sometimes 
acute oversensitiveness of hearing, but more often deafness. 
In some cases there is paralysis of the facial and trifacial 
nerves, and the senses of taste and of smell become blunted. 
The tendon reflexes are diminished and may be abolished. Der- 
mographia and facial herpes are frequently present. Kernig's 
sign is always positive. Pulse and respiration are accelerated, 
weak and irregular and Cheyne-Stokes respiration sometimes 
occurs shortly before death. There is almost always a rapid 
27 



4l8 PATHOLOGICAL OLD AGE 

loss of weight. Remissions occasionally occur and during 
apparent convalescence the symptoms will suddenly return 
with increased violence; in most cases, however, the disease 
progresses rapidly, delirium and then coma follow and the 
patient dies. A case may be protracted for several weeks, 
death finally ensuing as a result of exhaustion, . pulmonary 
edema, or other complication. Many cases die before it is 
possible to make a positive diagnosis. The presence of Kernig's 
sign points to meningeal disease and the prevalence of an epi- 
demic is presumptive evidence of the existence of the disease 
if there is prostration, lumbar pain and rigidity of the muscles 
of the neck. The onset in the aged is almost always clearly 
marked and can generally be diagnosed without the necessity 
of making a lumbar puncture to determine the character of 
the germs present. The finding of the diplococcus of Weichsel- 
baum in the cerebrospinal fluid or in the secretion of the nose 
makes the diagnosis certain. In the treatment of cerebrospinal 
meningitis good results have been obtained from the use of the 
Flexner antimeningitis serum. In the pandemic of 1904 to 
1908, the mortality where it was used was less than 25 per cent., 
while where it was not used the mortality was 70 per cent. 
It was less effective in senile cases than in younger ones. Lum- 
bar puncture with the withdrawal of from 20 to 40 c.c. of cere- 
brospinal fluid, replacing it by a like amount of normal saline 
solution, often relieves the symptoms temporarily. The pro- 
cedure must be repeated every second day. Ortner combines 
the two methods of treatment, replacing the withdrawn fluid 
by the antimeningitis serum. The hot bath treatment and 
Bier's hyperemia treatment cannot be applied to the aged, 
owing to the impaired circulation. Local disinfection of the 
throat and nose by means of peroxide of hydrogen is beneficial 
as a prophylactic measure. The treatment of the symptoms 
is directed principally to relieve the cerebral manifestations. 
The most important of these measures is the application of cold 
water, not ice, to the head and neck. This must be used 
continuously during the disease. Other remedies for the 
relief of the insomnia, headache, neuralgias, constipation, etc., 
must be selected with due regard to the condition of the heart 
and blood-vessels. Veronal, morphine combined with atropin, 
the bromides and aspirin may be used. 



ERYSIPELAS 419 

Acute articular rheumatism is almost always a recrudes- 
cence of a former attack. The symptoms do not differ from 
the disease in earlier life. In some cases there is little fever or 
swelling of the joints, but there is the same pain and stiffness. 
Occasionally, fever precedes the acute attack, and this pro- 
dromal fever may be higher than the fever that usually accom- 
panies the involvement of each new joint. In other cases there 
are marked cerebral symptoms, with hyperpyrexia showing a 
severe toxemia. These cases are grave, since they sometimes 
proceed to delirium, followed by coma and death. Acute endo- 
carditis, myocarditis and pericarditis, which are frequent com- 
plications of acute articular rheumatism in earlier Hfe, are rare 
in the aged. The only serious complication that occurs fre- 
quently is hypostatic congestion followed by pulmonary edema, 
and this can usually be avoided. 

The only disease which may be mistaken for acute articular 
rheumatism is gout and the differentiation should present no 
difficulty if we remember that gout generally affects the small 
joints, that intense exacerbations generally occur at night, and 
that there may be gouty deposits and a clear history of gout. 

The treatment of acute articular rheumatism in the aged 
is the same as in younger individuals. The aged require large 
doses of the salicylates, about 20 grains every four hours ; and 
morphine may be given if the pain is severe. The iodides are 
worthless in this disease in the aged. 

Erysipelas occurs frequently in persons of advanced years. 
Its favorite location is about the lower extremities, and it ap- 
pears there more frequently than in maturity, but it may also 
occur about the buttocks, face, head, hands and other portions 
of the body. The prevalence of erysipelas about the lower 
extremities is explained by the frequency of excoriations, vari- 
cose ulcers, eczema, scratches and abrasions, following pruritus 
in that locality. When occurring about the buttocks it follows 
bed sores; when on the face it follows some slight lesion about 
the nose, eye, corner of the mouth or elsewhere. Erysipelas 
of the scalp is usually an extension of the disease from the face. 
The source of infection in every case is a local primary lesion 
which may have been so insignificant that it escaped notice. 
Lack of cleanliness is a contributing factor in most cases. Ow- 
ing to the senile changes in the skin — atrophy of subcutaneous 



420 PATHOLOGICAL OLD AGE 

tissue, partial obliteration of capillaries, and diminished surface 
circulation — the local symptoms are generally modified. The 
redness is not as intense as in maturity, there being less infil- 
tration and swelling and little or no elevation of temperattire 
in the affected part. It is frequently localized in a small area, 
and spreads slowly. In some cases there are patches of ery- 
thema joined by fine reddish lines. It rarely spreads by the 
lymph spaces, mostly by surface extension. Sensations of 
heat and pain are much slighter than in earlier life and but 
rarely is there any involvement of the local lymphatics. Ves- 
icles, blebs, and pustules are seldom seen, but gangrene may 
occur in localities where the circulation is greatly impaired. 
The constitutional symptoms, Hke the local ones, are much 
milder in the aged than in earlier life. The onset may be 
abrupt, with a severe chill; more often there are slight chilly 
sensations followed by a rapid rise in temperature. The latter 
may be but little raised, rarely higher than 102°. The pulse 
and respiration are accelerated, but after defervescence of 
the eruption the pulse becomes slow and may drop to 50 per 
minute while the temperature may sink to 95°. Erysipelas of 
the face is often accompanied by bronchial catarrh; while 
erysipelas of the scalp is generally accompanied by cerebral 
symptoms such as intense headache, delirium, delusions, hallu- 
cinations, insomnia, etc. Albuminuria is generally present 
but other complications, which usually accompany infectious 
diseases, are rare. Relapses, however, may occur after an 
apparently complete recovery, and recrudescence months or 
years after the original disease had disappeared is not rare. 

The treatment of erysipelas is prophylactic, curative, symp- 
tomatic and hygienic. The principal prophylactic measures 
are cleanliness; antiseptic treatment of all wounds, ulcers, 
excoriations and scratches and the quarantine of cases w^hen 
they occur in institutions. The curative measures include 
serum therapy, which is still in an experimental stage, and 
measures to localize and diminish the eruption. For this 
purpose ichthyol is probably the most effective. It is brushed 
thickly over the affected area, covered with cotton, and allowed 
to remain until twenty-four hours after all local and constitu- 
tional symptoms have disappeared. This is superior to resorcin, 
guaiacol, nitrate of silver, or tinctiu*e of iron, the drugs that 



SEPSIS 421 

were formerly employed for the purpose. Hot fomentations 
sometimes relieve local pain, but they do not improve the general 
condition. Carbolic acid, the lead, mercury, silver, and other 
metallic salts are contraindicated in the aged. For the relief 
of distressing symptoms, like headache, fever, insomnia, pain, 
etc., the usual remedies for such conditions are required. Cold 
applications, not ice, can be applied to the head if cerebral 
symptoms appear. For the fever the preferable drug is quinine 
or salicylate of soda, but none of the coal-tar preparations 
should be used. Veronal may be given for insomnia. If local 
pain is severe, hot applications of tincture of opium or a 5 per 
cent, cocaine ointment can be applied. Internal analgesics are 
seldom required. The hygienic regulations require only a 
nutritious diet with little carbohydrate and no hydrocarbons; 
care of the bowels and kidneys, drinking large quantities of 
alkaline water if the renal secretion is deficient in quantity, and 
observance of the ordinary rules of health. 

SEPSIS 

Sepsis is used here to include septicemia and pyemia. Much 
confusion has arisen through different interpretations given to 
these and their allied terms toxemia, bacteremia and septico- 
pyemia. The last of these terms is superfluous, as every 
pyemia is septic and produces symptoms of septicemia. The 
term toxemia is usually applied to a condition in which bacterial 
toxins exist in the blood and bacteremia is applied to a condi- 
tion in which the bacteria themselves are present in the circula- 
tion. Septicemia is applied in its broadest sense to the disease 
produced by toxemia or bacteremia, while in its narrowest sense 
it is restricted to the disease caused by pus-forming germs 
or their toxins before secondary foci of suppuration have de- 
veloped. A localized pus formation in which the local symptoms 
predominate receives a local appellation as pyelitis, purulent 
pleurisy, abscess of the lung, etc. When the pus is carried in 
the blood and deposited in various localities, and the systemic 
symptoms predominate, the disease is pyemia. In furunculosis, 
for example, there are many local pus deposits but the systemic 
symptoms are mild. Pathologically it is a pyemia, clinically 
it is not. Ortner rejects the term pyemia and speak of it as 



422 PATHOLOGICAL OLD AGE 

metastatic sepsis, reserving the term true sepsis for septicemia. 
Other writers take different views. 

Sepsis like most other infectious diseases is infrequent in 
the aged and when it does occur it runs an atypical course. 
The usual channels of infection in the aged are surface lesions 
such as chronic ulcers, eczema, erosions, scratches, bed sores, 
etc., or the bladder infected by catheterization. Less frequently 
the channel of infection is the lower bowel, the nose, mouth, 
respiratory or digestive tract. In some cases the source of 
infection is in the gall-bladder or in the ducts, rarely in the 
serous membranes. 

The symptoms of septic infection in the aged differ somewhat 
from those of earlier life, the most pronounced differences 
being in the lower temperature and more frequent cerebral 
symptoms. Even in a grave form of sepsis the temperature 
rarely exceeds 103°. When due to the streptococcus the 
temperature is irregular, sometimes it is continuous for days, 
sometimes remittent or intermittent. The bacillus coli produces 
an irregular temperature with frequent slight chills, the tem- 
perature rising after each chill, then dropping until the next 
chill occurs. In some cases these chills come on at quite 
regular intervals and there is then a fairly regular rise and fall 
of temperature. The same condition may also be due to 
staphylococcic infection and this has been considered as dis- 
tinctive of pyemia. In many senile cases of sepsis the tem- 
perature does not rise above 98.5°. There is rapid heart action 
and rapid respiration in spite of the low temperature, frequently 
dyspnea, weak pulse and always some cerebral disturbance. 
This is generally evidenced by severe headache and insomnia, 
sometimes by more profound disturbances such as photophobia, 
delirium and coma, involuntary discharge of feces and urine, 
^and great prostration. The blood changes are generally similar 
to those of maturity but in debilitated patients, especially if 
the infection is severe, leucopenia may exist from the onset of 
the disease or may appear after a short leucocytosis. The 
spleen is rarely found enlarged, but this is only relative as the 
senile spleen is normally diminished in size. Constipation is 
usual owing to intestinal paresis. The cutaneous manifestations 
frequently found in earlier life are rare, except a temporary 
herpes, erythema or a roseola. The most serious and most 



SEPSIS 433 

frequent complication of sepsis is septic endocarditis. Apart 
from the danger to the heart itself, septic endocarditis gives rise 
to emboli which may be carried to any of the tissues, producing 
infarcts, abscesses, and hemorrhages. Abscess formation occurs 
most frequently with staphylococcic infection. The abscesses 
are usually small and scattered throughout the tissues so that 
their exact location cannot be determined. Occasionally an 
abscess is limited to a single organ such as the lung, or occurs 
in a single tissue such as a joint, or will burrow through ad- 
joining tissue and form a pocket at some distance from the 
original site. Occasionally a local septic inflammation with 
pus formation will destroy the enclosing tissue and the pus 
pouring into one of the large cavities causes a septic peritonitis, 
pleurisy, cellulitis, etc. 

Sepsis in the aged is usually fatal. It will not occur unless 
the resistance of the body is lowered and that alone implies 
lowered vitality. In the cases where surgical measiires can be 
taken to empty pus depots, recovery may follow. Where 
such depots cannot be reached or where there is a virulent, 
non-suppiu-ative septic infection a fatal issue may be expected. 
How far serum therapy will modify the prognosis is uncertain. 
In this, as in all other infectious diseases of the aged, the pro- 
found physical depression is of graver import than the local 
action of the germs. The prostration is often far greater than 
the extent or virulence of the infection would account for and 
persists after the disease germs have disappeared. Serum 
therapy of the future, if effectual, will destroy further germ 
activity and shorten the length of exposure of tissue to the 
deleterious influences of the germs, thereby removing complicat- 
ing factors. 

The invasion of most infectious diseases in the aged gives 
a very similar symptomatology and only bacteriological exam- 
ination can determine an early diagnosis. In a mild pyogenic 
infection there will be found a leucocytosis. This excludes 
typhoid fever, malaria, acute tuberculosis, influenza, and 
measles. In a virulent infection there is leucopenia with rela- 
tive increase of polynuclear leucocytes, while in the leucopenia 
of typhoid fever the lymphocytes are relatively increased. The 
Widal test and diazo reaction will differentiate typhoid 
fever. In the latter disease the initial prostration is more pro- 



424 PATHOLOGICAL OLD AGE 

found, the abdominal symptoms appear early and there are 
rarely chills, herpes, or the rapid pulse and respiration found 
in sepsis. When typhoid fever and sepsis are present at the 
same time the typhoid symptoms will completely mask the 
symptoms of sepsis unless abscesses form. The early differential 
diagnosis between sepsis and miliary tuberculosis may sometimes 
be made by the history either of a fibroid phthisis or other 
form of tuberculosis, or else of a surface lesion. Cyanosis 
and cough occur early in acute tuberculosis; late, if at all, in 
sepsis. The absence of catarrhal symptoms will exclude 
influenza, and malaria can generally be excluded by the history 
and the condition of the patient after the attack. 

The present-day treatment of sepsis is by serum therapy. 
The frequent failures where serums and vaccines are used arise 
from using a single strain of polyvalent vaccine in cases in 
which several forms of bacteria are active. Success by this 
method of treatment can be achieved only when we know the 
kind of bacteria we are dealing with and for that reason a 
bacteriological examination should be made before we select 
the serum or vaccine. A combined vaccine can be used if 
several forms of bacteria are found. In advanced arterio- 
sclerosis and weak heart the sera and vaccines are contraindi- 
cated. (French physicians recommend as a curative measiu-e 
the subcutaneous injection of colloidal metals such as elec- 
trargol, electroplatinol, etc. Their therapeutic value is uncer- 
tain, however.) 

Other measures in sepsis are either surgical or measures 
for the relief of symptoms. 

In the treatment of symptoms we must bear in mind the 
senile changes. We must not use powerful vasoconstrictors 
like digitalis, nor cardiac depressants like the coal tar products 
and chloral, nor drugs which inhibit peristalsis like belladonna 
and opium. Cold baths may produce a fatal shock and ice 
may destroy the surface circulation. The safest drug for 
reducing the temperature is quinine. Its action, however, 
is slow and it frequently causes gastric irritation. Heart 
tonics are required from the onset of the disease. The most 
available is caffein or coffee. In threatened heart failure 
we can use camphor, ether, or strychnine hypodermically. 
For the cerebral symptoms cold apphcations to the head, 



GONORRHEAL INFECTION 425 

and the bromides internally, and for insomnia we can use 
veronal or urethane. 

Care should be taken to secure free bowel and kidney 
action. Any of the peristaltic stimulants as aloin, cascara, 
castor oil, etc., can be employed to prevent constipation, and 
for the kidneys nothing will take the place of water. It can 
be taken in small quantities in short intervals, never in large 
quantities at a time, or it may be given by large rectal enemata 
slowly delivered several times a day. Where surgically ac- 
cessible pus depots exist, these should be cleaned out. When 
death without operation appears inevitable the most desperate 
surgical measures may sometimes succeed. 

Gonorrheal infection is rare in the aged as they expose them- 
selves less and there is apparently less susceptibility to the 
disease. Various hospital and dispensary statistics place the 
number of cases of gonorrhea between fifty-one and sixty 
years of age at little over i per cent, of the whole number of 
cases seen and above sixty years of age at a small fraction of 
I per cent. Gonorrhea in the aged female is extremely rare. 
The symptoms do not differ from those of earlier life. The 
disease is usually milder, but less amenable to treatment and 
is often followed by a postgonorrheal urethritis, but seldom by 
a prostatitis or stricture. Other complications are rare. An 
infectious non-gonorrheal discharge simulating gonorrhea is 
sometimes found in those who fail to observe antiseptic pre- 
cautions when using the catheter. The diagnosis in such a 
case rests upon the bacteriological findings. Prostatorrhea, 
spermatorrhea and simple urethritis may occur in the aged 
and give rise to the suspicion that a gonorrhea exists. These 
all require a microscopic examination to determine their char- 
acter. When a stricture is suspected a sound must be used. 
The stricture may be simulated by urethral spasm and com- 
pression of the urethra by a hypertrophied prostate. The 
former disappears after an injection of a 2 per cent, solution 
of cocaine in warm water. The latter gives other symptoms 
pointing to an enlarged prostate, while the history of gonor- 
rheal infection is absent. A postgonorrheal stricture, however, 
may exist at the same time with a hypertrophied prostate. 

The treatment of gonorrhea in the aged is the same as in 
young individuals. If there is a stricture, slow dilatation by 



426 PATHOLOGICAL OLD AGE 

means of sounds is better than the more rapid divulsion or in- 
cision methods. 

General infection, gonorrheal toxemia, gonorrheal arthritis, 
gonorrheal endocarditis and gonorrheal neuritis, etc., are ex- 
tremely rare in the aged. They must be considered among 
the possibilities, however, where there is a toxemia, arthritis, 
endocarditis, neuritis, etc., of unknown origin, but unless the 
specific organism is isolated in the blood or synovial fluid, we 
cannot make a diagnosis of systemic gonorrheal infection. If 
the diagnosis has been confirmed, we can use the gonorrheal 
vaccine, subcutaneously, as a curative measure. The septic 
and endocardial forms are usually fatal. 

SYPHILIS 

Syphilis is seldom acquired in advanced age. Persons 
having congenital syphilis rarely reach old age and old people 
do not expose themselves to the danger of infection as often as 
younger persons. Fournier reports of 10,000 cases, 207 between 
the ages of 51 and 61 and 40 between the ages of 61 and 71. 
Tertiary syphilis occurs more frequently, hospital records 
showing from 8 to 13 per cent, over the age of 50; of these, i to 
3 per cent, were between 60 and 70, and a small fraction of i per 
cent, over 70. In many senile cases the disease is acquired 
accidentally in old age and does not differ then materially from 
the disease in younger individuals. Sometimes the period of 
incubation is prolonged and the initial lesion persists longer. 
The sore is often larger and deeper than in maturity, it looks 
raw and in some cases it becomes gangrenous. The disease on 
the whole is usually more severe than in younger persons and 
secondary lesions may appear before the primary chancre has 
disappeared. The lymphatics become very slowly and at 
times not severely involved, but the cutaneous and nervous 
manifestations are more pronounced than in earlier life. A 
diffuse papulopustular syphilide is common. Syphilitic iritis 
is an early manifestation of the second stage. There is no sharp 
dividing line between the second and the third stages, the 
disease in the aged usually progressing without intermission. 
The pustules become ulcers, gummata form, the internal vis- 
cera become affected early, usually by the production of syphi- 
litic ulcers, the syphilitic cachexia is pronounced and often 
leads to fatal exhaustion. Quinquard found a constant de- 



SYPHILIS 427 

crease of the red blood cells, hemoglobin and of the albuminoids 
of the serum, the red cells numbering as low as 2,000,000. The 
central ner^'ous s\'stem is often profoundly affected, and there 
is usually mental depression, irritability, headache, sometimes 
insomnia and vertigo. 

In some cases the invasion of the secondary stage is like the 
invasion of an eruptive fever, with chills, fever, prostration, 
headaches, etc., and only the histon,^ the Wasserman test, or 
the finding of the spirocheta will determine the diagnosis of 
S3^phiHs. While French ph^^sicians generally ascribe greater 
virulence to the disease acquired in old age, the opposite view 
is held b}^ German physicians. American ph^'sicians who see 
many syphilitic cases confirm the French \T.ew. The disease, 
however, does occasionally appear in a mild form in the aged, 
the initial lesion is small, the secondarv^ s^'mptoms begin with a 
slight roseolar rash, the mucous membranes are not affected, 
there are no pains in the bones or joints, and tertiar^^ symptoms 
do not appear. Foumier described, under the name La Cachaxie 
adynamique, sl rare form of s^'philis in the aged. In this form 
there are pronounced constitutional s^^mptoms mth little or no 
local ones, except the initial chancre. There are mental and 
physical depression, anemia, anorexia, somnolence, progressive 
emaciation and exhaustion. In severe cases the fatal issue is 
reached in a few months, more protracted cases may last two or 
three years, death being due to exhaustion or pulmonary edema. 
Most cases of syphilis in the aged resemble the third stage of a 
syphilis which had been apparently cured years before. Four- 
nier reported a case in which the tertiary lesions appeared 
fifty-five 3^ears after the infection. In these dela^^ed cases of 
tertiary s^^philis the disease is generally mild and is confined to 
one locality or tissue such as the skin, mucous membrane, bone, 
etc. If a \-iscus is afi'ected it is generally by a chronic syphilitic 
ulcer, which gives little pain and no other clear s^^mptom. 

The finding of the spirochetae in the blood establishes the 
diagnosis Y.ith positiveness. If these are absent we can use 
the Wassermann reaction. A positive reaction means a positive 
diagnosis, but we may get a negative reaction though the disease 
be present. If both of these methods fail we have still the his- 
tory of exposure and initial lesion. This initial chancre is 
present in every case, but its site is not necessarity confined to 
the genital organs. Aside from the rare cases of syphilis inson- 



428 PATHOLOGICAL OLD AGE 

Hum or accidentally acqiiired syphilis, the frequency of sexual 
perversions in the aged, in whom the potentia coeundi has 
diminished, gives rise to unusual locations of infection. The 
unreliability of such perverts makes the history, as obtained 
from them, unreliable. A chancre should, however, give no 
difficulty in diagnosis and it is only after secondary or tertiary 
lesions arise, and history, as well as bacteriological examination, 
and Wassermann reaction are all negative that there can be any 
question as to the correctness of the diagnosis. During the 
second stage the brownish spots, mucous patches, atrophy of the 
glands at the base of the tongue and enlargement of lymphatic 
glands form a pathognomonic symptom-complex. Should there 
be any question of diagnosis in the tertiary stage we will usually 
be able to get a history of the symptoms of the secondary stage 
even if an initial chancre is denied. In questioning the aged 
where there is a suspicion of syphilis, more truthful replies will 
be obtained if we enquire about the secondary lesions without 
explaining the purpose of the questions, for they will generalty 
deny having had a venereal disease. The tertiary symptoms 
in the aged are frequently misleading. Syphilitic eruptions 
and sores do not itch, but the aged often suffer from a pruritus 
independent of syphilis and the cutaneous lesions may then itch. 
Sclerotic degenerations are more often due to senile changes 
than to syphilis and the same applies to anemia, emaciation, 
albuminuria, constipation, valvular diseases, all of them condi- 
tions which may be due to syphilis, yet which are found nor- 
mally in the aged. They may also occiir in tuberculosis and the 
differentiation between a tuberculous ulcer and a syphilitic 
ulcer will sometimes be impossible without a bacteriological 
examination, the Wassermann test or the tuberculin test. If 
all these diagnostic methods fail we must use the red or yellow 
iodide of mercury and observe the result, an improvement occur- 
ring in syphilis but not in tuberculosis. 

The treatment of syphilis in the senescent is the same as 
in maturity. The older method of treatment with mercury 
and the iodides is still the most reliable one and with slight 
modifications can be applied to the aged. The mercirry should 
be used by injection or inunction rather than by mouth and the 
insoluble salts are preferable to the soluble ones for internal 
administration. A salicylarsenate of mercury, is highly ex- 



GENERAL AXEMIA 429 

tolled by French physicians. Sodium cacodylate is much used 
in this countr^^ The old Donovan's solution of arsenious 
and mercuric iodides, containing the three antisyphilitic rem- 
edies, may be tried. Apart from the uncertainty of the action of 
the newer arsenical remedies such as salvarsan and neosalvarsan 
upon the senile organism, the aged will rarely permit a repetition 
of their intramusctilar injection o^ing to the pain, but an 
intravenous injection is free from this objection. For local 
manifestations of the disease, such as syphilitic ulcers including 
the primar>^ lesion, bismuth subnitrate and calomel in equal 
parts may be used as a dusting powder. If the chancre has 
become phagedenic it should be cocainized and touched mth 
a drop of acid nitrate of mxercury or of pure nitric acid. For 
the enlarged glands the oleate of mercury in a 5 per cent, 
ointment should be used. The scarlet red ointment is said to 
cure localized lesions. 

GENERAL ANEMIA 

The old classification of anemias into primary or idiopathic 
and secondary or symptomatic anemia is convenient rather than 
correct, as it is based upon etiological factors, the cause of some 
being unknown. These are progressive pernicious anemia and 
chlorosis, to which some authors add leukemia and pseudo- 
leukemia. It is not at all certain that pernicious anemia and 
chlorosis are not due to bacterial or toxic influences and hence 
are symptomatic anemias similar to the anemia of cancer or 
malaria. Anemia includes many forms of blood changes. In 
oligemia the entire quantity of blood is diminished. In hydre- 
mia the proportion of water is increased with the consequent 
proportionate diminution of the other elements. In oligocythe- 
mia the proportion of red cells is diminished. In hemoglobine- 
mia the percentage of hemoglobin in the cells is reduced. In 
leukemia the white cells are increased. In some forms of anemia 
the albumin content is diminished, in other forms there is a 
change in the character of the ceUs. All forms of anemia except 
chlorosis are found in the aged. 

Oligemia. — A diminution in the total quantity of blood in 
the aged was noted by Geist. This is due to the degeneration 
of the hemapoietic system, to contracted blood-vessels, obliter- 
ated capillaries and diminished thirst. The composition of the 



430 PATHOLOGICAL OLD AGE 

blood is not altered. This oligemia vera is marked in poorly 
nourished individuals in whom there exists atrophy of all the 
tissues, though the individual remains in fairly good health. 
This being a physiological condition in old age, nothing can or 
need be done for it. Inorganic salts of iron will not increase the 
hemoglobin percentage and the increased ingestion of food and 
drink wdll not improve the degenerated spleen or bone marrow 
nor the capacity of the blood-vessels. 

In traumatic oligemia, the diminished amount of blood is 
occasioned by hemorrhage. It may be a slow persistent bleeding 
as from hemorrhoids or cancer, or a sudden severe hemorrhage 
as when a vessel is cut. In sudden hemorrhage there is intense 
thirst, a physiological provision for replacing the lost fluid. 
The blood-forming tissues, however, are degenerated in the aged 
and repair proceeds slowly if at all. While in maturity the injec- 
tion of normal saline solution mil generally prevent the collapse 
following profuse hemorrhage, and will sustain the patient 
until the spleen and marrow have replaced the lost cells, the 
aged frequentty succumb, unless transfusion is performed. In 
slow persistent hemorrhage the cause must be removed if 
possible and nutritious food supplied. Iron medication in the 
aged is generalh' worthless. The inorganic f orm.s of iron are not 
readily assimilated and the organic preparations do not increase 
the hemoglobin percentage nor the number of red cells. Iron- 
holding foods such as green vegetables, salads, spinach, cabbage, 
3^oung beans, peas and lentils are recommended. Red bone 
marrow from the long bones of young animals will increase 
the number of red cells where the}^ are deficient, but the remedy 
soon becomes objectionable to the patient. 

Hydremia. — This is the usual condition of the blood when the 
cells are damaged by bacterial or toxic influences. It may also 
occur when there has been slow inanition with a large ingestion 
of liquids. 

Hydremia gives rise to local edemas, miliar^' hemorrhages, 
and to irregular heart action. The treatment depends primarily 
upon the cause. For the removal of the excessive amount of 
fluid, diuretics and diaphoretics must be used, the selection of the 
drug depending upon the condition of the heart and kidneys. 
The saline cathartics, in concentrated solution, are often effec- 
tive in tliis condition. 



OLIGOCYTHEMIA 43 1 

Albumin Deficiency. — Grawitz has shown that the anemia 
of inanition is not due to a deficiency of iron but to a general 
deficiency of albumin with consequent deficiency of albumin in 
the plasma. As a result of this impairment of the plasma the 
red cells degenerate. Whatever will cause disturbance in the 
assimilation of albumin will produce this form of anemia, and it 
is therefore f oiuid most frequently in gastric atony and dyspepsia. 
The treatment depends upon the cause. 

Hemoglobinemia. — The agents which destroy the red cells 
first release the hemoglobin, which is then carried by the serum 
to be converted in the liver and eliminated by the kidneys as 
hemoglobin or methemoglobin. As the hemoglobin is released 
before the destruction of the cell we find the hemoglobin per- 
centage proportionately lower than the cell count. In pernicious 
anemia the red cells though greatly diminished in number are 
generally very large and may contain then as much hemoglobin 
as the healthy cells, consequently we get a high color index in 
spite of a low blood count. In those cases in which there is 
a low hemoglobin percentage sterile iron by hypodermic in 
combination with arsenic may be tried or it may also be 
given in the form of hemoglobin and arsenic while manganese 
may be added. In every case, however, it is necessary to reach 
the cause of the anemia and remove that before we can expect 
permanent results. 

Oligocythemia. — Diminution of the number of red cells is al- 
ways found in anemia. In oligemia the proportionis maintained, 
but in every other form the proportion is reduced, the lowest 
number recorded being 143,000 per cubic millimeter, and that 
was in a case of progressive pernicious anemia. In anemia the 
red cells degenerate before they are destroyed and they present 
various abnormalities in size, shape, staining qualities, hemo- 
globin percentage, and the presence of nuclei. The principal 
causes for anemia in the aged are malignant disease, malaria and 
other infections, chronic suppuration, chronic dysenter\^ chronic 
nephritis, cirrhosis of the liver, metallic poisons, intestinal auto- 
intoxication and intestinal parasites. Pernicious anemia is 
believed to be due either to a specific micro-organism or to an 
autointoxication of gastric or intestinal origin. 

The only idiopathic, primar^^ form of anemia is oligemia. All 
other forms are secondary to another disease or part of a more 



432 PATHOLOGICAL OLD AGE 

comprehensive pathological condition. It is rarely possible to 
make a diagnosis of the underlying condition from the count or 
character of the red cells alone, as all the various abnormalities 
may be found in any of the severe anemias. Only in pernicious 
anemia must we depend upon the blood count for our final 
diagnosis. 

The most marked symptoms of anemia occur in profuse hem- 
orrhage. These are pallor, vertigo and faintness, prostration, 
palpitation, blanched mucous membranes, and cold perspiration. 
In the chronic anemias all these symptoms, excepting the pallor, 
are slight or absent. Most of the diseases associated with 
anemia, occurring in the aged, give distinctive symptoms apart 
from the anemia, and only progressive pernicious anemia need 
be considered as a distinct disease in which the blood changes 
present the main diagnostic factor. The hook worm disease, 
uncinariasis, resembles pernicious anemia in its symptoms, but it 
presents as a diagnostic sign the eggs or worms in the feces. 

Pernicious Anemia; Etiology. — The cause of pernicious anemia 
is unknown. Its course would indicate the activity of bacteria 
or of a bacterial toxin though no specific germ giving the dis- 
tinctive symptoms or producing the marked changes in the red 
cells has been found. In many cases there is undoubted intes- 
tinal autointoxication; in some cases lead poisoning and carbon 
dioxide poisoning have produced similar symptoms. Persistent 
bleeding from the gastrointestinal tract may give symptoms of a 
rapid progressive anemia. Other possible causes that have been 
suggested are degeneration of the marrow whereby regeneration 
of the blood is interfered with; atrophy of the stomach, this 
condition being frequently found after death; septic infection, 
septic lesions generally existing in the gastrointestinal tract, 
embryonic cells of another species of animal, etc. 

It seems probable that many substances which find their way 
into the blood have a deleterious influence upon the cells and 
cause rapid impairment and destruction. However, only a 
single etiological factor in the nature of a bacterial toxin can 
produce the profound cell changes found in a typical case of 
pernicious anemia. Many cases occtu-ring in the aged give the 
ordinary symptoms of pernicious anemia and show a low red cell 
count without the large number of megaloblasts or the extreme 
poikilocytosis found in the typical form of pernicious anemia. 



PERNICIOUS ANEMIA 433 

In these cases the bone marrow is found degenerated and the 
anemia is evidently due to impaired hemapoietic activity. In 
other cases the regulation of the diet by the withdrawal of all 
forms of animal albumin produces a rapid improvement. In 
some cases, however, there is a rapid poikilocytosis with a large 
number of megaloblasts, and the red cells are diminished to 
2,000,000 or less per cubic millimeter, and none of the measures 
employed to improve the digestion, eliminate poisons, control 
internal bleeding or overcome septic infection have the slightest 
effect upon the disease. 

Symptoms. — The most pronounced symptom of a typical 
case is a peculiar pallor, not sallowness as in cancer, but a waxy 
yellowish color. The mucous membranes are blanched and 
there is progressive bodily weakness without emaciation. The 
muscles become flabby, and slight exertion causes dyspnea and 
palpitation of the heart, with fatigue from which recuperation 
is slow. The appetite is usually lost and in most cases there are 
gastric and intestinal disturbances. Heart action becomes 
weaker and more rapid, systolic murmurs are heard over the 
mitral and aortic valves and blowing anemic murmurs over the 
aorta and sometimes over the carotids. 

Retinal hemorrhage and purpura are frequent and occasion- 
ally the symptoms of miliary hemorrhage in the brain appear. 
In those cases in which the absorption of the products of intesti- 
nal putrefaction is supposed to be the cause, the urine contains a 
large amount of indican and small amounts of cadaverin, and 
other substances derived from intestinal decomposition. 

The blood in pernicious anemia is profoundly altered. The 
red blood cells are greatly diminished while the hemoglobin 
percentage is not proportionately reduced. The cells are dis- 
torted in shape, there are many megaloblasts and a few normo- 
blasts while platelets are increased. The leucocyte count is 
diminished. 

As a result of the faulty nutrition of the tissues through the 
impairment of the blood, fatty degenerations occur most mark- 
edly in the heart and involuntary muscles. The diseases liable 
to be mistaken for pernicious anemia are Grawitz' cachexia and 
cancer. Grawitz' cachexia gives similar symptoms, but shows 
no blood changes. In some forms of cancer the only early symp- 
tom is the cachexia. This is associated with emaciation, the 
28 



434 PATHOLOGICAL OLD AGE 1 

pallor is a sallowness, there is leucocytosis and there is never the 
great reduction in number or the profound changes in the char- 
acter of the red cells that we find in pernicious anemia. Retinal 
hemorrhage is frequent in the latter disease, extremely rare in 
cancer. 

Pernicious anemia is a fatal disease though there are occa- 
sional remissions in the symptoms and occasional improvement in 
the character of the blood. Cases due to gastrointestinal dis- 
turbance are occasionally cured but it is doubtful if these were 
cases of true pernicious anemia. 

Treatment. — If an underlying cause can be found, that cause 
must be removed if possible. Where there has been absorption 
of the products of intestinal decomposition, as evidenced by the 
indican percentage in the urine, intestinal antiseptics and the 
exclusion of animal albumin and other purin-forming foods are 
necessary. Gastric digestion should be stimulated by lavage, 
pepsin and fruit acids or hydrochloric acid, and intestinal activity 
should be increased by the administration of pancreatin and the 
bile salts. The sulphocarbolates are the preferable antiseptics 
in these cases. 

Little can be done in cases due to persistent internal hemor- 
rhage. Adrenalin solution will frequently stop the bleeding but 
is dangerous in old age and may cause apoplexy. The lime salts 
increase the viscosity and coagulability of the blood and may 
stop internal hemorrhage. In many cases the bleeding comes 
from a cancer and surgical measures may be indicated. 

A pronounced oligocythemia without marked poikilocytosis 
points to degeneration of the blood-forming tissues. In these 
cases red bone marrow can be given, with hemoglobin, arsenic 
and manganese. If these measiires fail when given internally 
they should be given hypodermically. 

LEUKEMIA 

Leukemia presents no marked difference from the same 
disease of maturity. Both the myelogenous and the lymphatic 
types occur in the acute and chronic forms. The acute form, 
which is generally of the lymphatic type, is very rare in the old, 
and is usually fatal in from one to four weeks. It resembles in 
its coiu"se a malignant acute infectious disease, beginning with 



LEUKEMIA 435 

high fever, followed b}" rapid enlargement of the spleen and usu- 
ally enlargement of the h-mphatics of the neck, axilla, inguinal 
and other regions, hemorrhages from mucous surfaces, purpura, 
etc. The chronic form may exist as a slowly progressive 
cachexia for months before its nature is suspected. In some 
cases, glandular enlargement or abdominal distention is first 
noticed, in other cases bleeding from the gums or other hemor- 
rhages first attract the attention of the patient. There are 
numerous vague symptoms such as gastric and intestinal dis- 
turbances, nervous symptoms, headache, vertigo, irritability, or 
a general malaise with a feeling of being very ill indeed without 
being able to refer the sickness to any one organ or tissue. In some 
cases, especially in the aged, the symptoms point in many dif- 
ferent directions and it is impossible to make a diagnosis until 
the blood is examined. 

The blood changes in leukemia are distinctive and a single 
glance through the microscope will suffice to determine the diag- 
nosis. The leucocytes in myelogenous leukemia are increased 
from ten to two or three hundred times the normal number and 
many abnormal types appear. 

In the lymphatic type the leucocytosis is not as great, but 
the lymphocytes form from 75 to 99 per cent, of the whole num- 
ber of white cells. In no other disease is the leucocytosis as 
high, or are so m_any abnormal cells found. A lymphocytosis 
occurs in whooping cough, but here the clinical symptoms are 
distinctive. It also occurs in the rare diseases, myeloma and 
chloroma or green cancer. 

The treatment of leukemia is unsatisfactory. The acute 
form is generally fatal in a few weeks. The chronic form pre- 
sents occasional remissions with improvement under treatment, 
but relapses occur frequently. The most effectual treatment 
is by means of the X-ray and this has given even better results 
in the aged than in younger individuals. Of drugs, benzol has 
been used of late with remarkable success, and arsenic has had 
a proven beneficial effect. The latter is given in the form of 
Fowler's solution, beginning with i minim three times a day, 
and gradually increasing the dose a minim a day until the 
physiological effects appear, when its use must be discontinued 
for a few da^'s, after which the maximum dose is given continu- 
ously until the cumulative effects appear again. Quinine and 



436 PATHOLOGICAL OLD AGE 

iron, useful in younger individuals, have little or no effect in 
the aged. 



PSEUDOLEUKEMIC DISEASES 

Under pseudoleukemic diseases are included two diametri- 
cally opposite types, diseases resembling leukemia clinically 
but without the leucocyte changes and diseases having the 
leucocyte changes but not the symptoms of leukemia. Multiple 
lymphoma and splenomegaly belong to the first type, myeloma 
and chloroma to the second type. Lymphoma is seen occasion- 
ally in the aged, the others are rare and when occiu-ring they do 
not differ from the same diseases of earlier life. 

Lymphoma presents the clinical picture of a chronic leukemia 
in which the enlargement of the lymphatics is most marked. 
There is a slow progressive cachexia, the spleen is enlarged and 
hemorrhages from the mucous membranes as well as purpura 
are of frequent occurrence. The glands of the neck, axilla and 
inguinal region are most frequently affected. They enlarge but 
remain in their capsule and do not break down or ulcerate. 
Numerous other symptoms referable to the digestive, nervous 
and circulatory systems may appear. Fever points to infection. 
In making a diagnosis of this form of pseudoleukemia it is neces- 
sary to exclude leukemia and tubercular and syphilitic adenitis. 
The absence of leucocytosis and of abnormal cells will exclude 
leukemia. The respective serum tests may be required to elimin- 
ate tuberculosis and syphilis unless we can get a clear history 
of either. The disease may run a rapid course, or it may be 
slowly progressive, lasting for years before the cachexia causes 
fatal exhaustion. The treatment is mainly symptomatic, 
although arsenic and the X-ray have sometimes a beneficial 
effect, which is, however, not lasting. 

RHINITIS 

Acute rhinitis has the same etiological factors producing 
the same condition in earlier life, and the course of the disease 
is similar. Owing to the atrophic condition of the nasal mucous 
membrane, the local irritation is milder, there is less hypere- 
mia and not so much mucous secretion, but a greater tendency to 



; 1 



RHINITIS 437 

involvement of the nasophar^mx and conjunctivae. Local treat- 
ment is rarely required unless the secretion becomes mucopuru- 
lent, when mild, non-irritating antiseptics like boracic acid, 
thymol, and aristol may be employed by insufflation, or the 
simple alkaline antiseptic lotions used as a douche. An elevation 
of temperature with aching limbs, headache, labial herpes, etc., 
indicates a bacterial infection. This is rarely severe and re- 
quires only rest, warmth, and small doses of quinine or aspirin, 
or a combination of quinine and Dover's powder, giving 5 grains 
of each tmce daily. 

Chronic rhinitis occurs frequently in the aged, but the 
symptoms are usually so mild that no attention is paid to it. 
It occurs in persons who have frequent attacks of acute rhinitis 
or who are constantly exposed to irritating dust or vapors or 
rapid changes in temperature. When following repeated acute 
attacks, it begins as an atrophic rhinitis, the last attacks of 
the acute disease having left the mucous membrane dry and 
thin. When due to constant irritation it begins as a hyper- 
trophic rhinitis, with swollen mucous membrane and increased 
mucous discharge. The discharge becomes thicker and finally 
forms crusts, while the membrane underneath becomes thin 
and anemic. The crusts are irritating and cause the patient 
to remove them, thus leaving the underlying sensitive membrane 
exposed to further irritation. In many cases this leads to ulcera- 
tions which may extend to the bone and cause necrosis. There 
in a thin fetid discharge from the ulcerated membrane, the 
fetor becoming worse when necrosis of the bone occurs. This 
fetid coryza or ozena is usually ascribed to tuberculosis, but 
in the aged the ulceration and subsequent necrosis of the tur- 
binated bones are generally due to repeated irritation by the 
patient's finger nails. Owing to the loss of the sense of smell 
the patient does not perceive the offensive odor, and this condi- 
tion may persist for years before the injury to the bone will 
cause him to seek relief. There is generally marked erosion 
of the bones and the nasal cavity is enlarged, the nostrils being 
dilated by repeated stretching with the finger. 

Atrophic rhinitis can be cured at an early stage by local medi- 
cation. The nasal cavity should be thoroughly cleansed with 
an alkaline antiseptic solution, after which anhydrous lanoline 
should be appHed, the patient drawing it up as far as possible. 



43^ PATHOLOGICAL OLD AGE 

This should be done several times a day and continued for a week. 
At the end of a week the treatment should be omitted for a day 
to see if mucus still crusts. If this occurs the treatment should 
be repeated. After necrosis of bone sets in surgical intervention 
becomes necessary. 

DISEASES OF THE THROAT 

Acute pharyngitis is rather infrequent as the mucous mem- 
brane is usually atrophied and it requires a powerful stimulus or 
irritant to cause acute inflammation. The symptoms are gen- 
erally mild, there being Httle or no fever. The mucous mem- 
brane of the pharynx is not as red nor as swollen as in earlier 
life nor is deglutition greatly interfered mth. The local symp- 
toms rapidly subside upon spraying the throat with a i- 10,000 
solution of adrenalin repeated every three hours. A tempera- 
ture exceeding 100° in the aged points to an infection and the 
mucus should be examined for the spirillas of Vincent's angina 
and for staphylococci and streptococci. 

Vincent^s angina is seldom found in the aged and its symp- 
toms are much milder than in early life. The mucous mem- 
brane is covered w4th a yellowish or grayish exudate in which 
the pathogenic germs are found, there is a peculiar fetid odor to 
the breath and erosions and ulcerations of the mucous mem- 
brane of the mouth and throat occur. The constitutional 
symptoms are rarely severe. Frequent spraying with hydrogen 
peroxide followed by the application of tincture of iodine or a 
solution of iodoform in ether will generally cure this condition. 

Chronic pharyngitis occurs frequently in the aged as a dry 
atrophic condition. It is due to prolonged irritation from sub- 
stances inhaled or taken in food. A frequent cause is the in- 
halation of excessively dry warm air especially w^hen sleeping 
with the mouth open in a room heated by hot air radiators. The 
symptoms consist of a sense of dryness in the throat that causes 
persistent thirst, and irritation produced by the small amount of 
tenaceous mucus that is secreted and remains adherent to the 
pharynx, causing hawking and coughing in an effort to dislodge 
it. In dealing with this form of pharyngitis we must first dis- 
cover the cause. The atmosphere of the room can be kept moist 
by placing a vessel of water upon the radiators. To produce 



I 



DISEASES OF THE THROAT 439 

local stimulation a 2 per cent, solution of menthol in a normal 
saline solution should be used as a spray. As chronic pharyn- 
gitis is usually associated with chronic rhinitis, the treatment 
suggested under Rhinitis should be combined with the treatment 
of the pharyngeal condition. 

Acute tonsillitis is infrequent in the aged for the same reason 
that acute pharyngitis is rarely met with. The tonsil itself is 
usually atrophied and is rarely swollen. The treatment sug- 
gested for acute pharyngitis also applies to tonsillitis. 

Retrophar5mgeal abscess is rare. When it does occur the 
etiological factors, symptoms and treatment are the same as in 
maturity. The same also applies to peritonsillar abscess. Other 
affections of the throat such as tuberculosis, syphilis, and growths 
are rare and almost always secondary. They give no difficulty 
in diagnosis, and the treatment must be directed to the primary 
conditions. Various neuroses of the throat may appear in the 
aged, most of them being secondary to cerebral or nervous dis- 
orders. Their treatment involves the treatment of the under- 
lying condition. 

Syphilis may manifest itself in the throat in the form of 
gummata which break down and ulcerate. The diagnosis is 
readily made by the history and by the presence of other terti- 
ary lesions, while the Wassermann reaction is a conclusive test. 
The usual antisyphilitic treatment is indicated. For local 
treatment the ulcerated surface should be touched with a solu- 
tion of nitrate of silver or protargol or argyrol. Primary and 
secondary lesions are rare. 

Tuberculosis of the throat appears as a single or multiple 
ulcerations of the palate, pharynx or tonsils. They spread slowly 
by infiltrating adjoining tissue and do not heal readily. The 
tuberculin test may be necessary to determine their nature. 
Local treatment by the application of silver or zinc salts, and the 
constitutional treatment for tuberculosis is indicated. 

Growths of the throat are very rare in later life and are almost 
always secondary. Little need be said of them as they are purely 
surgical conditions and their diagnosis is simple. 

Neuroses of sensation and motion may occur, generally as 
part of psychic and nervous disorders, occasionally due to local 
irritation, as from tobacco, alcohol, hot food, ice, etc. Warm 
emulcent liquids may be employed to relieve hyperesthesia and 



440 PATHOLOGICAL OLD AGE 

spasm, and if these fail, spraying with a 2 per cent, cocaine 
solution will generally give temporary relief. The cure depends 
upon the underlying condition. 

LARYNGEAL DISEASES 

Acute laryngitis may arise in the aged from the same causes 
that produce the disease in younger individuals. The most 
frequent cause, however, is spasmodic cough. The senile 
atrophic mucous membrane of the larynx is not readily stimu- 
lated to acute inflammatory activity and for that reason acute 
laryngitis is not as frequent as it is in younger individuals. The 
disease is much milder, there is rarely any elevation of tempera- 
ture, the pain is not severe, and the feeling of some substance 
irritating the larynx, and inducing a cough, is not as pronounced 
as in the young. Hoarseness is, however, an early and per- 
sistent symptom and may proceed to complete aphonia. The 
laryngoscopic appearance of acute laryngitis presents redness 
and swelling but not as pronounced as in maturity; there is 
little mucus, and little change in the vocal cords. Unless soon 
relieved the disease becomes chronic, or by extension into the 
trachea and bronchial tubes, gives rise to a chronic bronchitis. 
The treatment is mainly hygienic, unless distressing symptoms 
appear. Rest in bed, warmth, a clear dry atmosphere, and 
abstaining from the use of the voice will generally effect a cure. 
Mild diaphoretics may be used and inhalation of a weak saline 
solution is often beneficial. If there is a persistent cough with 
scanty secretion, heroin and the syrup of senega may be used. 
Hot and cold applications and the applications of salt pork, etc., 
to the neck are concessions to the therapy of past ages. It is 
doubtful if these have any effect upon the disease. 

Acute submucous laryngitis is an extension from the mucous 
inflammation. It is very rare and occurs only when a grave 
acute laryngitis has been produced by a powerful irritant and 
the irritation persists. It may lead to stenosis of the larynx 
and necessitate tracheotomy. 

Perichondritis occasionally occurs in the aged, generally as a 
septic condition following infectious diseases, local ulcerations, 
metastatic abscesses, etc. It occurs in two forms, perichondritis 
interna and externa, the former consisting of an inflammation 
of the inner coat with swelling of the mucous membrane, the 



LARYNGEAL DISEASES 44 1 

latter as an inflammation of the outer coat with abscess forma- 
tion. In perichondritis interna the symptoms are those of 
acute laryngitis, with progressive stenosis, dyspnea and hoarse- 
ness leading to aphonia. In perichondritis externa the early 
symptoms are pain and fever; later, an abscess on the larynx 
forms, which may break down and cause constitutional septic 
symptoms. As the disease is almost always of septic origin, 
serum therapy may be of service. If this fails surgical inter- 
vention becomes necessary. 

Edema of the larynx may occur in the aged through impaired 
circulation in cardiac disease. It also occurs in nephritis, 
infectious diseases, chronic laryngitis, or as a result of the inhala- 
tion of irritating vapors, and other traumatic causes. It does 
not differ from the same disease in earlier life and must be treated 
the same way. When diaphoretics, diuretics and hydragogue 
cathartics fail, intubation or tracheotomy must be resorted to. 

Syphilis of the larynx is rare and the cases that do occur are 
almost without exception tertiary gummata. If seen early 
and while the growths are still small, they will disappear readily 
under salvarsan followed by the mercury and iodine treatment. 
After they begin to break down into syphilitic ulcers, cure is 
somewhat more difficult. Under antisyphilitic treatment they 
will gradually diminish in size, however, and disappear, leaving 
scar tissue behind, which, upon contracting, produces stenosis. 
In rare cases the ulcerations of the cartilages will cause destruc- 
tion of them and collapse of the larynx with asphyxia. 

Tuberculosis of the larynx is very rare in the aged. It 
manifests itself in ulcers which may appear in any part of the 
larynx. It is often impossible to differentiate between a tuber- 
ctilar and a syphilitic ulcer. The latter is usually clean looking 
and not painful, while the tubercular ulcer is usually covered with 
caseous debris and is painful ; the syphilitic ulcer has an exca- 
vated base with smooth everted edges, while in the tubercular 
one the edges are sloping and ragged. These distinctions, how- 
ever, are not always well marked and the differential diagnosis 
will then depend upon the history, associated symptoms and 
signs, the result of antisyphilitic treatment, and finally, serum 
tests. The treatment consists of cauterization by silver nitrate, 
or similar silver salts, lactic acid or weak chromic acid solution, 
and the application of orthoform in lo per cent, solution by 



442 PATHOLOGICAL OLD AGE 

means of a spray. The systemic treatment of the underlying 
condition is necessary. 

Neuroses of the larynx are infrequent and are then almost 
always associated with general psychic or nervous disturbances. 
Anesthesia is not recognized unless a laryngeal probe or other 
foreign body is introduced, when there will be found an absence 
of pain and reflex action. It is extremely rare, however. 
Galvanism is the appropriate remedy. 

Hyperesthesia sometimes occurs in acute or chronic laryngitis. 
A slight irritation, such as a change in the temperature of the 
air, or a dusty atmosphere, will cause coughing, while any more 
severe irritation will cause laryngeal spasm. 

The irritability can usually be allayed by spraying the larynx 
with a lo per cent, solution of orthoform or a 2 per cent, solution 
of cocaine. Spasm of the larynx may occur from intense irrita- 
tion, as from noxious vapors, dust, sudden temperature change 
in the inspired air, irritation of the vagus or of one of its laryngeal 
branches, excessive use of the vocal cords, or in hysteria or 
tabes. The treatment depends upon the cause. A whiff of 
chloroform may be required to allay a spasm. Laryngeal 
paralysis occurs occasionally in the aged. It may be due to 
hysteria or neurasthenia, bulbar paralysis, various spinal 
lesions, compression of the vagus or one of its laryngeal branches 
by growths, aneurysm, glandular enlargement, pericarditis, 
infectious diseases, poisons, muscle or nerve degeneration, 
cold, etc. 

The symptoms depend upon the nerve and muscles involved 
and are mainly connected with phonation. These symptoms 
are almost all due to unilateral or bilateral paralysis of the ab- 
ductors, adductors or tensors of the vocal cords. In paralysis 
of those muscles that are supplied by the rectirrent nerve, the 
patient is voiceless and unable to cough. In paralysis of the 
abductors there is dyspnea. Unilateral paralysis of these muscles 
is extremely rare. The adductors and tensors are usually para- 
lyzed together. If bilateral there is aphonia, if unilateral the 
voice is low and rough. 

The treatment depends upon the causative condition. For 
local treatment galvanism, faradization, and vibration are of 
service. Inhalation of creosote, menthol and ammonia can be 
tried. Local applications are of doubtful utility. 



DISEASES OF THE THYROID GLAND 443 

DISEASES OF THE THYROID GLAND 

Primary diseases of the thyroid are rare in senescence al- 
though some authors regard the normal senile degeneration of 
the thyroid gland as a form of myxedema. Horsley indicated 
many points of similarity between myxedema and the senile 
cachexia and thereon based his conclusion that the senile cachexia 
depends upon the degeneration of the thyroid gland — the more 
slowly this gland degenerates the slower the process of involution 
which causes the senile cachexia. 

Myxedema is, however, a pathological condition in which the 
symptoms have but a superficial likeness to the senile cachexia 
and it is doubtful whether the myxedemic degeneration of the 
gland is identical with the senile degeneration. The charac- 
teristic symptoms of myxedema are swelHng and infiltration of 
the subcutaneous tissue, dry scaly skin, general increase of the 
soft parts, and mental impairment. The skin of the face becomes 
swollen, especially about the eyes and chin, the nose and mouth 
become thickened and the face has a dull, heavy, expressionless 
appearance. The tongue becomes thick, and is protruded with 
difficulty. The hands and feet increase in size and may lose 
their contour. There is diminished surface sensibility, all other 
senses become blunted, the mind weakens, the will is impaired 
and responses to stimuli are slowed. These symptoms are suf- 
ficiently pronounced to distinguish it from senile cachexia. 
The treatment consists of the administration of thyroid gland 
or an extract of it which must be continued for weeks after the 
symptoms have disappeared or until palpitation of the heart 
announces that it has exceeded the limit of its therapeutic effect. 
To prevent a relapse a dose should be taken at regular intervals. 
Thyroid extract has no effect upon the senile cachexia. 

Bronchocele and exophthalmic goiter are very rare in the 
aged, and they do not differ from the disease of earlier life. A 
bronchocele carried over from maturity may decrease in size and 
disappear in the process of involution without treatment. 

Cancer of the thyroid may occur as a primary disease, giving 
the usual symptoms — namely, rapid increase in size, cachexia 
and infiltration of neighboring lymphatics. Kocher says it 
occurs most frequently in locahties where goiter is endemic and 
attacks almost exclusively those in whom the thyroid is degen- 
erated. The treatment is surgical. 



444 PATHOLOGICAL OLD AGE 

Tuberculosis may occiir as part of a miliary tuberculosis but 
caseous degeneration of the former as well as gummous degen- 
eration of syphilis are very rare. Acute thyroiditis is rare and 
does not differ from the disease in early life. 

DISEASES OF THE ADRENALS 

Little is known of the diseases of these glands in the aged. 
Addison's disease has been noted, but it does not differ from the 
disease in earlier life. Grawitz has described a growth upon the 
glands, which is occasionally found in old people and which 
begins as a benign tumor but may become malignant. Cancer 
and other growths, such as caseous and gummous degenerations, 
have been observed as secondary conditions, but they give 
no distinctive symptoms apart from the symptoms of the pri- 
mary disease. 

ACUTE BRONCHITIS 

Etiology. — ^Acute bronchitis in old age has a similar sympto- 
matology to the same disease of earlier life. Owing to the atro- 
phy of the mucous membrane in the aged, a much more powerful 
irritation is required to cause an acute inflammation and there 
is a greater tendency to involve the finer tubes and to run a 
chronic course. Great stress has been laid upon the influence 
of bacteria in the production of acute bronchitis and other acute 
inflammatory diseases. The senile organism is, however, more 
or less immune to bacterial influences, and when such infection 
does occur, it is either because the resistance had been lowered 
through disease or debility, or because the germs were exception- 
ally virulent. In either case the disease is much graver than in 
earlier life. When the inflammation is due to local irritation, 
and this is generally the case, it either subsides upon removal of 
the irritation, or it becomes chronic. Acute bronchitis also 
occurs frequently as a secondary infection in the course of an 
infectious disease and in these cases the infection rapidly in- 
volves the finer tubes and produces a bronchopneumonia. 

Symptoms. — The symptoms of simple non-infectious acute 
bronchitis are much milder than in younger individuals. There 
is little or no pain nor any sensation of oppression in the chest, 
no fever, and little irritation, hence less tendency to cough. 



ACUTE BRONCHITIS 445 

The expectoration is scanty, thick, not purulent and is frequently 
swallowed. The physical signs are less marked. There are 
usually dry rales, but occasionally moist rales and prolonged 
expiration are found. If the capillaries are involved, these 
symptoms become aggravated, and there is a sense of oppression; 
dyspnea sets in, the cough is more severe, and powerful efforts 
must be made to loosen the tenacious mucus in the capillaries 
and to expel it. The respiratory murmur varies, it being weak 
or lost over a section in which the bronchial tubes are filled with 
mucus, and distinct where the tubes are clear. Fine and coarse, 
dry and moist rales are heard, fine moist rales being evident 
during inspiration over an area in which the capillaries are 
filled with mucus. Extension into the lung tissue may occur, 
producing bronchopneumonia. The infectious form of acute 
bronchitis begins with fever, headache and malaise. The local 
symptoms — cough, pain and expectoration — are more marked 
than in earlier life ; the disease invades the bronchioles and finer 
capillaries and produces the infectious form of bronchopneu- 
monia. An increase in temperature in a non-infectious case 
points to infection. 

Treatment. — Simple non-infectious acute bronchitis requires 
no treatment apart from hygienic measures and the removal 
of the cause. Counter-irritants like mustard or surface hyper- 
emia produced by dry cups over the chest, or hot foot baths, 
will hasten recovery. Of the expectorants the syrup of hypo- 
phosphite of ammonia liquefies the mucus, ipecac increases its 
flow, and senega acts as an irritant to the mucous membrane, 
thereby increasing the tendency to cough. The narcotics — 
morphine, codein, heroin and dionin — relieve the pain, but 
dull the sensibility and lessen the irritation, thereby preventing 
cough, which is necessary to remove the accumulated mucus. 

While hygienic measures are of primary importance in 
simple acute bronchitis, drug treatment is more important in 
the capillary form. The choice of drugs depends upon the 
condition of the mucus and upon the ability of the patient to 
expectorate it. The ammonia salts, the carbonate, chloride 
and hypophosphite, liquefy the mucus ; senega and apomorphine 
aid in its expectoration. Apomorphine cannot be used if the 
heart is weak. Ipecac, squills, and grindelia, all increase the 
amount of mucus and should be used whenever it is scanty. 



446 PATHOLOGICAL OLD AGE 

Narcotics, if required, should be given in combination with 
the other drugs. In the infectious form the treatment of capil- 
lary bronchitis should be followed. Frequent percussion of the 
chest is necessary to recognize the presence of pneumonia. 
Inhalation of creasote, guaiacol or thiocoU is beneficial in this 
condition. The heart should be watched and strychnine given 
if it becomes weak. Hygienic regulations are rest, a dry equable 
atmosphere (free from dust and smoke) in a low elevation, 
warm baths, light foods, no alcoholics and no excitement. 

Fibrinous bronchitis is extremely rare in the aged. When 
it does occur it does not differ from the same disease of earlier life. 

BRONCHIAL STENOSIS 

Etiology. — The caliber of the trachea or of a bronchial tube 
may be diminished in the aged by various conditions such as 
pressure from without, a hyperplasia of the lining membrane, 
scar tissue, a growth within, a foreign body or muscular spasm. 
Owing to the multiplicity of causes which can produce stenosis, 
the disease is not rare. Stenosis of the trachea occurs most 
frequently where goiter is endemic. Aspiration of foreign 
bodies such as inspissated mucus or food particles is a frequent 
cause of bronchial stenosis in the aged. Pressure from mthout 
may be caused by a growth, aneurysm, enlarged gland, or by 
traumatism. Inflammatory sw^elling of the lining membrane 
is rare and scar tissue and growths in the trachea or bronchus 
are likewise very exceptional. Spasm may occur in bronchial 
asthma, in hay fever and as a result of intense irritation. 

Symptoms. — Difliculty in respiration is the most prominent 
symptom. This may occur slowly, rapidly or suddenly, depend- 
ing upon the cause. If mild, it gives trouble only upon exertion ; 
if severe it produces a marked dyspnea, and if complete it causes 
asphyxiation, depending upon the location and extent of the 
occlusion. It is often difficult to determine the cause of dyspnea 
or the exact place of the stenosis. Sudden dyspnea occurs in 
spasm and in occlusion caused by a foreign body. Dyspnea 
without cough occurs in compression stenosis. In stenosis of 
the trachea or bronchial tube, however, the cause is usually 
evident and the location can be determined thereby. Upon 
auscultation there is normal respiration below the point of 



PERICARDITIS 447 

contraction, a whistling sound at the point, and weak, higher 
pitched respiratory sounds above. In stenosis of a fine tube, 
atelectasis of the part of the lung supplied by the occluded tube 
may occur. 

Treatment. — Treatment depends upon the cause. Surgical 
measures are generally required. 

PERICARDITIS 

Acute pericarditis is rare but pericardial adhesions are not in- 
frequent. In most cases these adhesions date from early age 
when the pericarditis appeared as a complication of or following 
an acute articular rheumatism or some other infectious disease. 
In some cases there is a history of cardiac disease, in others a 
nephritis was the immediate precursor of the pericarditis. The 
acute disease in the aged does not differ from the one of earlier 
life. It begins as an adhesive pericarditis followed by a sero- 
fibrinous exudate. There is dulness on percussion, the apex im- 
pulse is weakened or absent, and fever, pain and dyspnea are 
present. A friction sound over the heart, synchronous with the 
heart contractions and not influenced by respiration, is path- 
ognomonic of pericarditis, but this friction sound may be absent 
in the presence of an extensive exudate. The disease is more 
serious in the aged than in younger individuals, as it is usually 
associated with acute endocarditis and myocarditis arising from 
the same etiological factors that occasion the pericarditis. Re- 
covery from the acute disease is rare and is then always followed 
by a chronic adhesive pericarditis with obliteration of the peri- 
cardial sac or adhesion to the pleura or chest wall. When the 
layers of the pericardium are adherent to each other there may 
be no symptoms at all or only friction sounds. When the peri- 
cardium is adherent to the pleura or chest wall there is displace- 
ment of the heart and consequent disturbance of its action. 
Prominent symptoms are a dimpling or retraction over the apex 
beat at each systole, the paradoxical pulse and a diffuse dias- 
tolic impulse. The symptoms are more pronounced in adhesion 
to the vertebras. There is then a considerable hypertrophy, 
which is generally followed by dilatation of the heart with its 
complications. 

The treatment of acute pericarditis in the aged comprises 



44^ PATHOLOGICAL OLD AGE 

rest and attention to the symptoms. The iodides may be given 
internally and a hyperemia may be produced over the region of 
the heart if there is much exudation, and if this fails it may be 
necessary to withdraw the exudate through a pericardial canula, 
always a dangerous operation in the aged. For a pericardium 
with adhesions to the chest wall, Brauer suggested a resection of 
portions of the ribs with separation of the adhesions. Drugs are 
useless in these cases except to relieve symptoms and to tempo- 
rarily stimulate the heart. 

Chronic mediastinitis usually accompanies a chronic pericar- 
ditis but it gives no distinctive symptoms and it is treated as 
part of the pericarditis. 

GASTRIC ULCER 

Gastric ulcer is rare after the sixtieth year. In its etiology 
and pathology it does not differ from the same disease of earlier 
life but the symptoms in advanced age may be modified by the 
changes in the stomach walls. 

Symptoms. — Gastric ulcers have been found upon autopsy 
which gave no symptoms during life, while in other cases the first 
indication of an existing iilcer was a fatal hemorrhage or gas- 
tric perforation. In maturity the classical symptoms are pain, 
hematemesis and hyperchlorhydria. In the aged, normal or 
subnormal acidity occurs more frequently than hyperacidity, the 
pain is often slight and may not occur until two or three hours or 
more after taking food. There is a persistent ache, however, 
which only gives way to the more acute pain that follows the in- 
gestion of food. This pain is rarely paroxysmal, but becomes 
gradually worse, until it has reached its maximum intensity, then 
it lessens, leaving an ache which persists. The pain is usually 
localized over the site of the lesion, most frequently in the me- 
dian line below the sternum. 

The hematemesis is rarely severe, yet it is a grave symptom. 
The aged do not vomit readily and when it occurs it signifies 
a severe irritation or hemorrhage. A severe gastric hemorrhage 
may be rapidly fatal or cause a cachexia from which the patient 
does not recover. Generally, there is a slight regurgitation of 
food an hour or two after eating, and in the matter brought up 
there will be a trace of blood, either as a small black clot or as a 



GASTRIC ULCER 449 

particle of food streaked with blood. In suspected ulcer the 
food thus brought up should be carefully examined for this sign 
of the disease. Blood can sometimes be found in the feces, but 
it is then impossible to determine its exact source. The appe- 
tite is not impaired and there may even be a bulimia. The in- 
gestion of food generally gives temporary relief from pain but the 
knowledge that the pain will appear later produces a fear of food. 
In many cases there is pyrosis, flatulence, eructations of gas, 
constipation, etc. 

The only diseases which may give similar symptoms are can- 
cer of the stomach, and ulcer of the duodenum. The pain of 
cancer is not as sharp, but it is more persistent, and occurs 
soon after the ingestion of food, the hemorrhage is darker, 
''coffee ground vomit," and there is a pronounced hypochlor- 
hydria with the presence of lactic acid. There is progressive 
cachexia, glandular involvement and later a tumor can be felt 
at the site of the cancer. In duodenal ulcer the pain occurs 
several hours after eating, and it radiates to the back on both 
sides of the spine. Food and alkalies give relief from pain while 
flatulence increases it. The tender point is usually about the 
umbilicus. Vomiting is rare and does not give relief from pain. 
Jaundice is occasionally present and blood is often found in the 
stools. 

Other diseases giving gastric pain, like gastralgia, the gastric 
crises of tabes, acute gastritis, etc., have pathognomonic symp- 
toms, or histories, or are not accompanied by hematemesis, 
while cirrhosis of the liver, in which there may be vomiting of 
blood, has no gastric pain. Erosion of the mucous membrane 
of the stomach, which has been considered a preliminary stage of 
gastric ulcer, has not been observed in the aged (Ewald). 

Treatment. — The treatment of gastric ulcer does not differ 
from the treatment of this disease in younger persons. The 
most important indication is to prevent further irritation of the 
lesion and this can be done only by withholding all food as long 
as possible and resorting to rectal feeding. This can generally 
be done for three or four days, when bland articles of diet, such 
as calf's-foot jelly, oat-meal gruel, milk, and malted milk may 
be given. In the meantime bismuth subnitrate in lo-grain 
doses combined with an equal quantity of magnesium carbonate 
should be given three or four times a day. The treatment 
29 



450 PATHOLOGICAL OLD AGE 

should be continued for a week and afterward more substantial 
food may be permitted. Alcoholics, spices, and acids must be 
avoided and as little salt as possible should be taken. If the 
pain is severe hypodermics of morphine and atropia may be used. 
Cocaine will allay the irritability which leads to vomiting, 
but unless there is nausea, it should not be used. Severe gastric 
hemorrhage and perforation are almost invariably fatal. If 
hemorrhage occurs, tannic or gallic acid may be used as astrin- 
gents and pieces of ice should be swallowed. The danger in these 
cases is more from shock than from the amount of blood lost 
and the shock should receive attention as soon as the patient 
has received the ice or the astringent. The most rapid and 
effectual treatment is a hypodermic injection of 30 minims of 
ether. Surgical intervention may become necessary. 

DUODENAL ULCER 

Duodenal ulcer is rare after the sixtieth year. Its etiology 
and pathology is the same as in younger individuals. 

Symptoms. — Symptoms are generally vague and the diagno- 
sis must often be determined by excluding gastric ulcer, gastric 
cancer, gall-stone colic, intestinal colic and peritonitis. The 
pain is localized about the umbilicus, and appears from three 
to four hours after eating. It is relieved by food and by alkalies. 
There may be griping pains, after the pains produced by the 
chyme and the discharge of acid into the duodenum cease. 
Pressure over the site of the ulcer intensifies the pain. Vomiting 
is rare, but the feces generally contain a trace of blood. Flatu- 
lence produces a sharp pain, jaimdice is sometimes present 
and the stools are then clay-colored. 

Treatment. — The treatment is as for gastric ulcer, including 
surgical intervention, butpredigested foods can be given through- 
out the disease and alkaline mineral waters are admissible. 

ENTERITIS 

Under this name will be described acute and chronic inflam- 
mations of the intestines including localized inflammations 
such as colitis, typhlitis, proctitis, etc. It is often impossible 
to localize an intestinal inflammation and in many cases of 



ACUTE ENTERITIS 451 

enteritis more than one portion of the bowel is involved. Inflam- 
mation of the rectal wall can usually be diagnosed by inspection; 
inflammation of other portions of the bowels rarely give such 
clearly defined symptoms that their exact location could be 
determined. They will, therefore, all be included under one 
head, and where localized inflammations present special symp- 
toms these will be mentioned. 

ACUTE ENTERITIS 

Etiology. — According to Ewald an acute interitis can occur 
only in the healthy senile individual. If there is the ordinary 
senile degeneration of the intestines present, the acute inflam- 
mation becomes converted into a chronic one as soon as the acute 
symptoms lessen in severity. 

The most prolific cause of acute enteritis in the aged is 
improper or excessive food. Owing to the lessened peristaltic 
activity, food remains longer in the bowel and, owing to the 
diminished bile and intestinal secretions, it decomposes more 
readily and this decomposing material irritates and inflames 
the lining membrane of the intestines. The most common food 
articles that rapidly decompose are cold storage meat and eggs 
and canned foods, over-ripe fruit, and tainted milk. Certain 
articles of food will produce in some persons a catarrhal condi- 
tion with diarrhea, and the change from hard to soft drinking 
water will often give the same effect. The prolonged use of 
drugs, especially of inorganic salts, will cause an acute enteritis, 
although generally by the time this enteritis is recognized it 
has entered a chronic stage. A change or deficiency in the 
gastric or intestinal secretions which permits undigested food 
to pass into the lower bowel will cause an enteritis which usually 
begins and progresses so mildly that it becomes chronic before 
it attracts attention. Only a sudden and profound change in 
the secretions will produce an acute inflammation with acute 
symptoms. Infection, the invasion of animal parasites, chilling 
of the surface of the body and nervous influences, such as shock, 
fear or other strong emotion, may cause an acute catarrhal 
inflammation of the intestines. An acute enteritis may be 
secondary (i) to an inflammation or ulceration, (2) to gangrene 
or cancer in an adjoining tissue which by extension has involved 



452 PATHOLOGICAL OLD AGE 

the bowel, (3) to an acute infectious disease, or (4) to local 
circulatory disturbances. 

Pathology. — Owing to the physiological senile degeneration 
of the mucous membrane of the intestinal tract, the inflammatory 
changes as found on abdominal section in maturity are mild or 
absent in senility. There may be a slight hyperemia and an 
increased flow of mucus from enlarged mouths of mucous glands, 
more often there are areas showing desquamation of epithelial 
cells, enlarged follicles, and areas of ulceration. 

Symptoms. — The most prominent symptoms of acute enteri- 
tis are pain and diarrhea. The pain is usually colicky, coming 
on spasmodically and is partly relieved by pressure. An inflam- 
matory pain, continuous and intensified by pressure, indicates 
an extension of the inflammation to the peritoneum or other 
viscus. If the upper bowel is affected the pain is more severe 
and persistent. In inflammation of the jejunum or ileum the 
pain is most severe at the umbilicus. In the lower bowel it is 
rather a dull ache, rarely intense or paroxysmal, but tenesmus 
is usually present. In proctitis there is always tenesmus, a 
burning sensation in the rectum and, if the inflammation is due 
to a foreign body or to a hard mass of feces pressing against 
the sphincter, there is a sharp, cutting pain. In typhlitis the 
symptoms are referable to the appendix which is usually in- 
volved also (see appendicitis). In cases where improper or 
excessive food is the cause, the pain comes on suddenly two or 
three hours after the food has been taken. When due to a toxin 
it may come on in a few minutes after ingestion of food. If 
due to cold the pain is usually mild and if due to nervous influ- 
ence there is frequently entire absence of pain. Tenesmus is 
always due to rectal irritation. 

Diarrhea is the most distinctive symptom of enteritis, yet 
it may be absent. The stools are at first soft, then watery, 
the normal intestinal contents being carried away by the first 
few movements. Much can be learned from the character of 
these evacuations. If the early ones contain feces in small 
lumps, the upper bowel is involved ; if the feces are formed then 
the trouble lies in the descending colon or rectum. Mucus 
generally indicates inflammation of the large intestines though 
minute particles may come from the small bowel. Formed 
feces covered with mucus indicate proctitis. Cecal mucus is 



ACUTE ENTERITIS 



453 



generally dark and jelly-like, while the color becomes lighter 
and the consistency more fluid the nearer the inflammation is 
to the anus. Strips or bowel casts, indicating a mucous colitis, 
are rare. Blood is seldom found in the enteritis of the aged. 
When it is present it points to a serious complication, or to 
dysentery. A sour-smelling stool is due to excessive carbo- 
hydrate fermentation; a foul-smelling one indicates intestinal 
decomposition or else dysentery or carcinoma. Pus is found in 
ulcerative enteritis. Food remnants appear in the stool if the 
duodenum is involved. Yellowish, greenish, or grayish dejec- 
tions come from the upper bowel. In the enteritis due to cold 
or nervous influences, the dejections are watery and generally 
odorless, passing without pain or tenesmus. In almost all 
diarrheas the discharges irritate the rectum and will sooner or 
later produce tenesmus. 

In addition to the pain and diarrhea there are generally 
tympanites, borborygmi, sometimes cramps in the muscles of 
the abdomen and legs, vomiting and intense thirst but no 
elevation of temperature unless there is some infection. Vomit- 
ing is infrequent in the aged. The urine becomes scanty and 
high colored and may contain a trace of albumin and casts. 
If the small intestines are affected there will be an increase of 
indican. The symptoms are usually more severe than in earlier 
life, although the alvine discharges may be reduced in quantity 
and frequency owing to the atrophy of the lining mucous mem- 
brane and glands. In many cases of acute enteritis there is 
rapid exhaustion which may terminate in collapse and death. 

Treatment. — The principal indications for treatment are 
the diarrhea and pain. The measures for the relief of the 
diarrhea depend in part upon the location and in part upon the 
cause of the enteritis. In all cases it is necessary to secure 
thorough evacuation of the bowel before checking the diarrhea. 
If the inflammation is in the rectum this can best be accom- 
plished by a high enema using an alkaline solution. If in the 
upper bowel, castor oil should be used, but if this cannot be 
taken another vegetable cathartic, preferably rhubarb or 
cascara, should be used. These drugs act slowly, evacuation 
following in from twelve to twenty hours. If rapid action is 
required we must employ the saline cathartics in large doses and 
given in hot water. In many cases the removal of offending 



454 PATHOLOGICAL OLD AGE 

material from the bowels and rest will relieve the diarrhea and 
if care is taken with the diet for a day or two there will be com- 
plete recovery from the enteritis. If the diarrhea is due to cold, 
the application of moist heat will give relief, and if due to sudden 
emotion the relief of the nervous symptoms is generally all that 
is necessary to check it. When diarrheal discharges continue 
after the bowels have been cleared, they should be checked by 
the use of astringents, preferably bismuth subnitrate in lo-grain 
doses. Opium in 1/4-grain doses should be added if there is 
much pain. For the pain alone a hypodermic injection of 
morphine and atropine can be used. For the relief of tenesmus 
a suppository of extract of belladonna and opium gives relief. 
The powerful mineral astringents, like sulphate of copper or 
zinc, are rarely required, but if the discharges continue to have 
a foul odor the sulphocarbolate of soda or zinc should be used. 
All astringent drugs should be discontinued as soon as the 
diarrheal discharges cease. Incidental symptoms, such as 
tympanites, borborygmi and muscle cramps pass away as soon 
as the bowels have been evacuated. Thirst should be relieved 
by ice, not by excessive draughts of water. The danger from 
exhaustion and collapse is much greater than in younger indi- 
viduals. In these cases brandy acts well and strychnine should 
be given if the pulse becomes weak. 

During an attack of acute enteritis the food should be light, 
bland, fluid and preferably predigested. Food liable to decom- 
pose or ferment in the intestines should be prohibited and on 
the first day of an acute attack all food should be avoided. After 
the first day small quantities of some predigested food may be 
given for a day, after which more substantial nourishment can 
be permitted. Cold storage meat and canned food should never 
be used in cases showing a tendency to diarrhea or flatulence. 
If the diarrhea is followed by constipation, mild vegetable 
laxatives should be employed. 

CHRONIC ENTERITIS 

Etiology. — Chronic enteritis in the aged is usually secondary 
to an acute attack. A slow, progressive enteritis is produced 
when undigested food passes into the lower bowel or when there 
is excessive intestinal fermentation and decomposition. The 



CHRONIC ENTERITIS 455 

prolonged use of inorganic salts may produce a slow progressive 
enteritis. It may also occur as a secondary condition following 
intestinal ulceration or other lesions, or may be due to chronic 
circulatory disturbances or to diseases of metabolism. 

Pathology. — In mild cases no changes can be found. There 
is usually some thickening of the mucous membrane with 
erosion and pigment deposits in or around the follicles. Passive 
hyperemia with ecchymotic spots is sometimes found, and occa- 
sionally there are bands of dark thickened, or of light atrophied, 
membranes between them. 

Symptoms. — The most prominent symptom of chronic 
enteritis is a diarrhea alternating with constipation. In the 
progressive form there is a gradual increase in the number and 
fluidity of the stools, these occurring most frequently in the 
morning. The character of the stools is the same as in acute 
enteritis and there are often the same incidental symptoms, flat- 
iilence, tympanites, borborygmi, and pain. The pain, however, 
is usually slight, rarely colicky. If ulcerations are present there 
will be tenderness over the site of the ulcer and pain on pressure. 
Localization of the inflammation is difficult, yet the determina- 
tion of its place is necessary to secure a proper dietary. Lien- 
tery points to duodenitis and this diagnosis is confirmed if there 
is jaundice and pain at or above the umbilicus. 

In inflammation of the ileum or jejunum there is also some 
pain or tenderness about the umbilicus with occasional colicky 
pains, the stools are fluid, gra3dsh or greenish, and have a sour or 
foul odor. The pain comes on two or three hotirs after eating. 
A typhlitis gives a brownish partly formed thick stool covered 
with a dark jelly-like mucus, pain is in the right groin and the 
feces have the usual fecal odor. Symptoms of appendicitis 
may be present. Cohtis produces a large fairly formed stool 
covered with a light mucus and the pain comes on a few minutes 
before the stool is passed. The pain can be more readily local- 
ized in the ascending, transverse or descending portion of the 
colon than in any other part of the bowel. 

Proctitis has an almost pathognomonic symptom, tenesmus, 
with painful dejections. The stools are formed and are covered 
with mucus. The presence of pus, blood, or shreds of mucus in 
the dejections indicates an ulceration, and the location can 
generally be determined by the intense pain produced when 



456 PATHOLOGICAL OLD AGE 

pressing upon it. It is important to differentiate between syph- 
ilitic, tubercular and simple ulcerative enteritis, but the former 
two can generally be diagnosed by the history and attending 
symptoms. Carcinoma of the intestines may simulate chronic 
enteritis, but the intense pain, presence of tumor, cachexia and 
involvement of other tissues will serve to differentiate it from the 
milder affection. 

Treatment. — The treatment is primarily dietetic. The diar- 
rhea can in most cases be temporarily controlled by intestinal 
astringents, or, if the fault lies in the rectum or colon, by 
starch enemata. The most important point in the treatment of 
chronic enteritis is to avoid the introduction of irritating sub- 
stances into the bowel. Food liable to ferment or decompose, 
strongly acid substances, and food containing much indigestible 
matter must be avoided. An examination of the stools should 
be made, and if food particles are found, such substances must be 
avoided or given in a predigested form. Especially objection- 
able on account of their indigestibility are vegetables containing 
much cellulose, meat containing much cartilage, tendon or 
connective tissue, skin and fatty smoked meats. Readily de- 
composing foods are cold storage meat and eggs, all canned food, 
and overripe fruit. 

Medicinal measures are confined to intestinal astringents 
and antiseptics, and for the occasional constipation, mild 
vegetable laxatives. Proctitis alone can be treated locally by 
astringent lotions and enemata and, if there is much pain or 
tenesmus, by cocaine and belladonna suppositories. 

DISEASES OF THE LIVER 

Cirrhosis of the liver is infrequent after the sixtieth year and 
the hypertrophic form is extremely rare in advanced life. The 
infectious diseases play an insignificant role in the etiology of 
cirrhosis of the aged, and owing to the natural atrophy of the 
organ, the enlargement in the hypertrophic stage is not marked. 
For a similar reason the enlargement of the senile spleen, which 
is a prominent symptom in earlier life, rarely reaches the size 
of the normal organ in maturity. Gastrointestinal disturbances 
arise early and there are, occasionally, gastric and intestinal 
hemorrhages and frequently bleeding hemorrhoids. Ascites, 



DISEASES OF THE LIVER 457 

which occurs late in maturity, occurs early in senility, but rarely 
reaches the extent seen in earlier life. The general disturbance 
of the circulation and nutrition causes a more profound senile 
cachexia, the complexion being sallow or tending toward jaun- 
dice with cyanotic patches about the nose and cheeks. There 
are occasionally shooting pains, and more frequently tenderness 
upon pressure over the liver. Cerebral symptoms develop late 
in the disease. 

A positive early diagnosis of hepatic cirrhosis in the aged is 
impossible, the early symptoms being usually referred to the 
stomach and bowels. The history of the prolonged use of al- 
cohol on an empty stomach is suggestive, and the enlargement 
of the liver points to cirrhosis. A definite diagnosis can be made 
later when atrophy sets in and ascites and gastric or intestinal 
hemorrhages occur. Primary cancer of the liver in an alcoholic 
subject may be mistaken for cirrhosis in the hypertrophic stage. 
If nodules cannot be felt it may be impossible to differentiate 
them until secondary symptoms of the cancer, or atrophy and 
ascites of cirrhosis, appear. Cancer of the liver progresses more 
rapidly than cirrhosis, the cachexia is more marked and appears 
earlier, and there is no ascites. Cardiac disease and peritonitis 
often present some of the symptoms of cirrhosis, but they have 
some pathognomonic symptoms of their own. The treatment 
of cirrhosis of the liver is unsatisfactory. Drugs have no effect, 
but may relieve the associated symptoms. A salt-free diet will 
sometimes retard the anasarca but where it fails, diuretics, hy- 
dragogue cathartics and diaphoretics must be used. The ques- 
tion of early or late paracentesis depends upon attending cir- 
cumstances. Some authors suggest tapping at the earliest 
possible moment to prevent extreme distention and weakening 
of the abdominal muscles, others suggest that it be deferred 
until the dyspnea, cyanosis or pulmonary edema endanger life. 
Diuretics are usually ineffectual in extreme ascites and hydra- 
gogue cathartics may cause exhaustion. It seems best to tap 
early and reduce the edema by diuretics, repeating the operation 
whenever the abdomen is again distended, and not to delay until 
dyspnea or cyanosis make it imperative. A milk and simple 
vegetable diet, the administration of simple bitters with the ad- 
dition of hydrochloric acid, and but little liquid food with the 
exception of milk are the principal dietetic regulations. Alcohol 



458 PATHOLOGICAL OLD AGE 

must be absolutely prohibited. Other treatment is purely 
symptomatic. 

Hypertrophic cirrhosis, Hanoi's cirrhosis, is extremely rare. 
It resembles the hypertrophic stage of atrophic cirrhosis, but 
the liver does not atrophy, there is no ascites, though there is 
jaundice but without the clay-colored stools that occur in other 
diseases that are accompanied by hepatogenous jaundice. The 
disease is slowly progressive and incurable. The treatment is 
symptomatic. 

Syphilis of the liver appears as a tertiary, diffuse, inter stitial 
hepatitis, or as gummata. In the former case the disease re- 
sembles atrophic cirrhosis with but slight ascites, and cachexia, 
in the latter case there are growths upon the liver which can 
usually be felt, they may produce pressure symptoms, but cach- 
exia is slight. In both cases there are symptoms of tertiary 
syphilis in other tissues. The history and the Wassermann test 
will determine the diagnosis. The usual antisyphilitic treatment 
is indicated. 



HYPEREMIA OF THE LIVER 

Active hyperemia may be physiological, as when occurring 
after a full meal, or pathological when due to infectious and toxic 
diseases. The later is rare in the aged and when it occurs it lasts 
as long as the underlying disease lasts. There is a sense of oppres- 
sion, tenderness on pressure, enlargement of the organ, some- 
times jaundice and diarrhea. The treatment depends upon the 
cause. Small doses of calomel may relieve the congestion 
temporarily. 

Passive hyperemia : Etiology. — This is a common ailment in 
the senile and generally occurs with cardiac dilatation or with 
other cardiac diseases. Anything which obstructs the flow 
through the vena cava or hepatic vein will cause hepatic venous 
stasis. 

Pathology. — The liver passes through several stages beginning 
with enlargement due to venous engorgement, followed by 
hyperplasia of connective tissue and pigmentation of the cells, 
producing the nutmeg liver, and lastly degeneration of the cells 
and atrophy, forming the atrophic nutmeg liver. The disease 



HYPEREMIA OF THE LIVER 459 

producing no discomforts until a later stage, the physician seldom 
sees the patient during the first stage. 

Symptoms.— During the early stages there may be a sense of 
weight in the region of the liver, tenderness on pressure and en- 
largement of the organ, but the early symptoms are not well 
marked, the liver being normally contracted in advanced life. 
Later there is impairment of the functions of the organ, exhibited 
in gastrointestinal disturbances, clay-colored stools, constipa- 
tion, dark urine, sallowness or jaundice and cachexia with mental 
depression. The liver is diminished in size and tender. 

Treatment. — The treatment depends upon the underlying 
condition. Calomel, blue mass or bile salts are indicated in- 
ternally, and counter-irritation externally, by sinapisms, leeches, 
dry cups, etc. 

Abscess of the liver is rare. The solitary or tropical abscess 
is occasionally found in dwellers of warm countries and usually 
follows amebic dysentery. Multiple or pyemic abscesses occur in 
pyemia. Embolic abscess, a solitary abscess, is extremely rare. 
The symptoms are the constitutional symptoms of septic 
infection with local symptoms of pain, tenderness, sometimes 
a feeling of weight or dragging when lying on the left side, 
enlargement of the organ, occasional digestive disturbances, 
dyspnea, cough, ascites and jaundice. Diagnosis of multiple 
abscess is often difficult as the local symptoms may be mild 
and escape notice. The disease may be mistaken for empyema, 
but the latter disease has earlier symptoms of pleurisy. 

Rupture gives symptoms of shock and profound sepsis. 

Treatment is surgical. Serum therapy may be tried for the 
systemic disease. 

Fatty degeneration may occur as part of general obesity, as a 
result of alcohol or poison, or in the course of some infec- 
tions, and in cachexias. The disease gives no distinctive 
symptoms. The liver may be enlarged, but is not nodular or 
painful and there is no jaundice or cachexia unless these are 
due to a primary disease. The treatment depends upon the 
underl3ring condition. 

Amyloid degeneration is very rare in the aged. The liver 
becomes greatly enlarged and the border can be felt as a sharp 
ridge but it gives no distinctive symptoms. The treatment 
depends upon the cause. 



460 PATHOLOGICAL OLD AGE 

DISEASES OF THE PERITONEUM 

Primary Acute Peritonitis. — It has been declared that a 
primary acute non-infectious peritonitis does not occur. Cases 
of acute peritonitis following traumatism, however, do occur 
without any evidence of bacterial action, though such cases 
are extremely rare. 

Secondary acute peritonitis may be due to extension of an 
inflammation from an adjoining tissue, or to a perforation into 
the abdominal cavity. This disease, which is infrequent in 
the aged, does not differ from the peritonitis of earlier life except 
that the local symptoms are milder, and the constitutional 
symptoms are graver, while the disease is almost invariably 
fatal. The exudate is fibrinous, serofibrinous, hemorrhagic, 
purulent or gangrenous. In some cases there is no pain except 
upon motion, and cases are found without elevation of tempera- 
ture. In severe cases there is complete anorexia and insomnia, 
which often cannot be relieved by drugs. 

In senile cases the invasion is frequently gradual, without 
chills, and with but little pain, which, however, rapidly increases 
in severity, while several days may elapse before the abdomen 
becomes distended. In these cases the peritonitis is an exten- 
sion of an inflammation from a neighboring inflamed tissue. 
Constitutional symptoms of septic infection are present in 
many cases. Peritonitis is differentiated from intestinal occlu- 
sion by the fever and pain which are present at the onset, while 
in obstruction the pain appears later and complete constipation 
is present from the first. There is besides generally a history 
leading to the production of the disease which will aid in 
the diagnosis. The disease is usually fatal in a few days. 
Serum therapy may possibly hold a cure for this as for other 
infectious diseases. Surgical measures have availed in some 
cases in earlier life and as a last resort may be tried in the aged. 
The usual treatment with opium relieves the distress but does 
not cure. It is hardly necessary to mention the numerous 
remedies that have been proposed for the treatment of perito- 
nitis as none are curative. In rare cases where the peritonitis 
comes on slowly as a result of an inflammatory extension from 
an adjoining organ, absolute rest will be followed by a subsidence 
of the acute symptoms and the disease may become chronic. 



CHRONIC PERITONITIS 46 1 

Chronic peritonitis may follow an acute attack, or a prolonged 
peritoneal irritation, such as in ascites, or it may be due to 
tuberculosis or cancer. Occasionally, after abdominal section, 
the symptoms of a mild peritonitis appear, probably as a result 
of the irritation of the peritoneum during the operation. 

The symptoms are the same as those of acute peritonitis 
but are less intense and more prolonged. The constitutional 
symptoms are mild, or absent or masked by the more pronounced 
constitutional symptoms of the underlying disease. The course 
of chronic peritonitis is a slowly progressive one unless due to 
cancer when the progress is usually rapid. The exudate may 
form bands or adhesions and cause constriction or displacement 
of organs and tissues, producing intestinal obstruction or occlu- 
sion, displacement of the ovaries, uterus, stomach, liver, or 
other abdominal organs. Many uninterpretable symptoms 
are found upon autopsy to be due to peritoneal adhesions with 
consequent displacement of abdominal organs. 

The diagnosis is generally based upon the history. If there 
is any question between chronic peritonitis and ascites, it will 
be necessary to resort to paracentesis and consequent examina- 
tion of the exudate. The serous exudate in peritonitis has a 
high specific gravity (1015-1024, Ewald) and it has a decided 
tendency to coagulation and production of fibrin. The serous 
exudate of ascites has usually a specific gravity below 10 15 
and may remain fluid. Cysts are rare in the aged and there is 
usually a localized swelling in a region in which peritonitis is 
infrequent. An ascites and a peritonitis may exist at the 
same time, the irritation produced by the ascites causing 
peritonitis. 

There is no cure for this condition. The symptoms may be 
relieved and the fluid withdrawn, but its withdrawal increases 
the danger from peritoneal adhesions. If these adhesions cause 
intestinal occlusion, or other grave symptoms, operation may 
be necessary. 

Ascites is a symptom of numerous pathological conditions 
which cause disturbance in the abdominal circulation, or produce 
a general hydremia. The most frequent of these in old age 
are diseases of the heart and lungs which cause passive con- 
gestion of the abdominal vessels, obstruction of the portal circu- 
lation, chronic peritonitis, nephritis, cancer, and the pressure of 



462 PATHOLOGICAL OLD AGE 

tumors. Tubercular, chylous and adipose ascites are extremely 
rare in the aged. 

The diagnosis of a collection of fluid in the abdominal cavity 
ought to give no difficulty. Cysts are rare in the aged, and are 
unilateral and localized in the organs which contain them. 
Bladder distention has been mistaken for ascites — an unpardon- 
able error. The treatment of ascites depends upon the cause. 
The local treatment is by paracentesis. This should be done as 
early as possible and the fluid withdrawn slowly, care being 
taken to first empty the bladder. It is often possible to retard 
future exudation by the use of ditiretics, diaphoretics, and hy- 
dragogue cathartics, the selection being determined by the con- 
dition of the heart, kidneys and general strength of the patient. 



DISEASES OF THE PANCREAS 

Apart from cancers which, according to Ewald, form about 
60 per cent, of all pancreatic diseases, the most frequent patho- 
logical condition of the pancreas found in advanced life is the 
chronic pancreatitis associated with diabetes mellitus. In 
this disease there is a proliferation of the interstitial connective 
tissue and degeneration and atrophy of glandular tissue. There 
are no distinctive symptoms. Usually, however, we find 
gastric and intestinal indigestion, emaciation, sometimes jaun- 
dice, epigastric pain, lipuria, glycosuria, and fatty stools. In 
rare cases it is possible to feel the indurated pancreas, thereby 
confirming the probable diagnosis. There is no curative treat- 
ment for this condition. The relief of symptoms and the 
administration of diastase, bile salts and pancreatin with all 
starchy food is the most that can be done. 

Acute Pancreatitis. — This may occur as a hemorrhagic or 
suppurative pancreatitis, both exceedingly fatal conditions. 
It begins with intense pain in the region of the pancreas, vomit- 
ing and collapse. The abdomen becomes distended and tender 
and there is usually constipation. The sudden onset of the dis- 
ease without previous illness or history distinguishes it from in- 
testinal perforation, intestinal obstruction, perforation of a 
peptic ulcer and from gall-stones. Death usually occurs in a 
few days. 



DISEASES OF THE SPLEEN 463 

DISEASES OF THE SPLEEN 

Primary diseases of the spleen are extremely rare and second- 
ary diseases are infrequent. The acute swelling of the spleen 
that generally accompanies inflammatory and infectious dis- 
eases is not as pronounced as in earlier life and can rarely be 
diagnosed as the organ is physiologically atrophied and even 
marked enlargement will not reach the normal size of maturity. 

The same applies to the chronic enlargement that accompanies 
diseases of the liver and also to local passive hyperemia in cir- 
culatory disturbance. Such swellings of the spleen produce no 
symptoms. The extreme swelling of splenomegaly may cause 
pressure symptoms but this condition is very rare in the senile. 
Acute splenitis occurs usually as part of the systemic disturbances 
occasioned by acute infectious diseases; rarely as the result of 
trauma or of extension of an inflammation from an adjoining 
viscus. It is generally accompanied by a perisplenitis and is 
then painful upon pressure over the spleen. The treatment 
depends upon the underlying cause. Local applications of hot 
moist cloths will relieve the pain. Chronic splenitis may follow 
an acute splenitis, while a gradual induration with hypertrophy 
may occur in the course of a chronic infection or disease of the 
liver. In this, as in all diseases of the spleen in which this organ 
is enlarged, excepting splenomegaly, the hypertrophy of the 
atrophied gland rarely reaches in size the normal volume of the 
gland in maturity. Consequently there are absent the sense of 
weight and oppression and the pressure symptoms that are char- 
acteristic of the enlarged gland in earlier life. In inflammatory 
conditions the location of pain may clear up the diagnosis. In- 
farction of the spleen may occur in the aged but there are no 
distinctive symptoms. Abscess usually follows an infarct and 
may give symptoms of a mild septic infection, the only symptom 
indicating its location being tenderness upon pressure over the 
organ. The treatment is surgical. There is no record of the 
result of serum therapy in this condition although its employ- 
ment would be in harmony with its use in other cases of septic 
infection. 

Splenoptosis occurs frequently as part of the general viscerop- 
tosis of advanced life. It gives no marked symptoms and is 
generally discovered accidentally while percussing the abdomen. 



464 PATHOLOGICAL OLD AGE 

The displacement is most pronounced in women who were ac- 
customed to tight lacing. If the displacement produces much 
discomfort, it can generally be relieved by a binder with a pad 
which will hold the organ in place. 

Other conditions, such as tuberculosis, syphilis, growths, 
amyloid degeneration, cysts, etc., are extremely rare in the aged. 
When present they are usually secondary and give no distinctive 
symptoms apart from the symptoms of the primary disease. 

DISEASES OF THE KIDNEYS 

Acute or active hyperemia of the kidneys is generally due to 
irritation from drugs, while toxemia from infectious diseases, 
the most frequent cause in earlier life, is infrequent in the aged 
and acute parenchymatous nephritis, in which acute hyperemia 
is the initial condition, is extremely rare. There are no clearly 
defined symptoms of acute hyperemia beyond a pain or a dull 
ache over the kidneys which is increased upon pressure. The 
urine generally contains blood and albumin but no casts. The 
diagnosis must be made from these symptoms and from the 
history of the ingestion or use of irritating drugs. The treat- 
ment demands the removal of the causative irritation, and the 
administration of large quantities of alkaline water. 

Chronic or passive hyperemia occurs frequently in the aged as 
a result of impaired abdominal circulation caused by disease of 
the heart, lungs, liver, or pressure from growths. Arteriosclero- 
sis may be a causative factor, although the usual result of this 
condition is an anemia with consequent atrophy, due to mal- 
nutrition. The kidney in passive hyperemia is enlarged, 
congested and deep red in color, darker in the pyramids than 
in the cortex. There is no marked increase in connective 
tissue and no degeneration of the epithelium of the tubes. The 
symptoms are almost exclusively associated with functional 
activity, as evidenced by the urine. The quantity is diminished, 
the specific gravity is increased, and may reach 1030 or more, 
the solid constituents are increased, the percentage of urea 
and uric acid being high. There is usually albumin but rarely 
blood or casts. The diagnosis is readily made from the exam- 
ination of the urine. The treatment depends upon the cause. 
No irritant diuretics should be given. 



UREMIA 465 

Anuria or total suppression of urine may occur in the course 
of any renal or infectious disease, or as the results of traumatism, 
shock or occlusion of both ureters. It may arise suddenly 
as in shock, rapidly as in infectious disease or slowly, the amount 
of urine decreasing day by day until there is complete anuria, 
as in chronic hyperemia. Unless speedily relieved uremia 
follows but recoveries have been recorded even after total 
suppression lasting fifteen days. Treatment depends upon the 
cause. In some cases vegetable diuretics w411 produce such 
irritation that free diuresis is followed by complete suppression. 
In such cases bland or lithia water may be taken and at the 
same time hydragogue cathartics and diaphoretics should be 
given to remove the excess of fluid. In some cases hot baths or 
the Turkish bath will stimulate all excretory secretions. Gen- 
erally vegetable diuretics like uva ursa, buchu, digitalis or 
juniper are required. If there is edema or symptoms of ap- 
proaching uremia a salt-free diet should be gradually instituted 
and more powerful diuretics such as potassium acetate or nitrate, 
and hydragogue cathartics should be used. 

Uremia is usually of the chronic type, is associated with 
arteriosclerosis or chronic interstitial nephritis, and is ac- 
companied by a persistent w^atery diarrhea. The gradually 
increasing nervous and cerebral symptoms ending in convulsions 
and coma, and the diminished excretion of urine and solids 
determine the diagnosis. Mild symptoms may persist for years, 
with acute exacerbations, during w^hich convulsions, dyspnea, 
Cheyne-Stokes respiration, and coma may occur. Cases are 
occasionally met with which give a number of vague symptoms, 
such as headache, insomnia, vertigo, neuralgic pains, increasing 
mental dulness, impairment of sight, hearing and other senses, 
various gastric and intestinal disturbances, etc., and a diagnosis 
of general arteriosclerosis is made imtil a uremic coma suddenly 
discloses the underlying condition. In all such cases it is 
necessary to determine the amount and character of the urine 
for several days in succession in order to make a correct diag- 
nosis, yet this is rarely done. The most important part of the 
treatment of chronic uremia is a salt-free diet which in the 
aged, must be gradually introduced. Diuretics should be used 
to increase the action of the kidneys and diaphoretics and 
saline cathartics should be given to increase elimination of 
30 



466 PATHOLOGICAL OLD AGE 

waste. If there is a nephritis present the saline diuretics 
should be used instead of the irritating vegetable ones. The 
oils and balsams are contraindicated. Pilocarpine is dangerous 
if the heart is weak. Narcotics may be required for convulsions. 
Albuminuria in the aged if not in large amount and not as- 
sociated with casts is generally of no importance and indicates 
only a senile, contracted kidney. It is, however, necessary 
to exclude other causes for albuminuria which may prevail, 
such as temporary irritation of the kidneys by drugs or toxins, 
febrile states, changes in the composition of the blood. The 
treatment of the albuminuria due to above-mentioned factors 
depends upon the cause. 

Hematuria may be of renal, in-eteral, vesical or iu*ethral 
origin. Renal hematuria in the aged is always a grave symp- 
tom indicating either a profound change in the blood or an in- 
tense irritation and congestion of the kidney. Ebstein reported 
a case of an aged patient with hemorrhagic infarct of the kidney 
and hematuria with rapid recovery, but such cases are rare. 
The principal causes of renal hemorrhage are nephritis, acute 
hyperemia, calculus, cancer, papilloma, pyelitis, tuberculosis, 
infarction, traumatism, infectious diseases, pernicious anemia, 
leukemia and late cirrhosis of the liver. Ureteral hematuria 
is generally due to impacted calculus or to the passage of a 
rough-edged stone. Vesical hematuria is usually due to vesical 
calculus, acute cystitis, ulcer or growth in the bladder. Hemor- 
hage from the urethra is generally due to traumatism or en- 
larged prostate. In renal hematiuia the blood is intimately 
mixed with the urine and is smoky ; in vesical hemorrhage the 
first part of the urine voided is clear, in ureteral hematuria 
the blood appears in small clots, while urethral hemorrhage pure 
blood can be pressed out of the urethra. 

Hemoglobinuria occurs in cases in which the red blood cells 
are destroyed by infection, toxins, or drugs, or by diseases like 
pernicious anemia, leukemia, scurvy, etc. 

The urine in hemoglobinuria resembles the urine of hema- 
ttuia but there are no blood cells in the former. 

Hematuria and hemoglobinuria are incidental symptoms 
occiurring in many diseases and while not pathognomonic of 
any, they have a corroborative value of the greatest importance. 
In hemoglobinuria the kidneys are usually not affected, in 



CHRONIC PARENCHYMATOUS NEPHRITIS 467 

hematuria of renal origin the kidneys are usually diseased either 
primarily through local irritation or secondarily through blood 
changes. 

The treatment depends upon the cause. Local treatment 
is useless in hemoglobinuria as the causes lie in the blood. In 
renal hematuria benzoate of ammonia in 5 -grain doses is some- 
times of benefit when due to infectious disease, and camphor 
in 5 -grain doses when due to drug irritation. Astringents are 
of service in vesical hematuria. The underlying cause must 
be treated in all cases. 

Pyuria occurs in all suppurative conditions of the urinary 
organs and passages. It will also occur when an abscess in an 
adjoining tissue breaks into a urinary passage. The most 
frequent causes in the aged are cystic infection introduced by 
the catheter and vesical and renal calculus. The recognition 
of pus in the urine is of importance in the differential diagnosis 
between senile non-infectious cystitis and chronic infectious 
cystitis. It may also direct attention to the location of an 
infection giving constitutional symptoms, but no pronoimced 
local ones. 

Other urinary abnormalities are occasionally met with, but 
they present no marked difference in etiology or diagnostic 
value, from those of earlier life. Indican is usually found in 
larger quantities than in maturity, while the amount of mucus 
and calcium salts is diminished. 

Acute nephritis is generally due to acute irritation by drugs. 
Scarlet fever, diphtheria, typhoid fever and other infectious 
diseases which are the principal etiological factors in early life 
are very rare in the aged. Expostu-e to cold and wet, another 
potent etiological factor in younger individuals, is also less 
prevalent in the aged. The disease does not differ from the acute 
nephritis in younger life and requires the same treatment. It 
occasionally becomes chronic. 

Chronic parenchymatous nephritis is rare and when occtu- 
ring follows the same course and presents the same symptoms 
as in younger individuals. It is, however, a graver disease from 
the onset, the symptoms are more pronounced and it passes 
through the three stages rapidly, death, due to uremia, some- 
times occiuring within a few months after the acute initial 
symptoms have appeared. It is rarely prolonged beyond a 



468 PATHOLOGICAL OLD AGE 

year. No plan of treatment has been successful where the 
degenerative changes due to the active inflammation have been 
added to the senile degeneration. The plan of giving a salt- 
free diet cannot be followed in the same manner as in younger 
individuals, as the sudden withdrawal of salt causes anorexia 
and inanition with consequent rapid exhaustion. Salt, alco- 
holics, coffee, etc., to which the patient may have been accus- 
tomed for years, must be withdrawn gradually. The exclusive 
milk diet has the same objection since large quantities must be 
taken to supply sufficient nutrition. Malted milk is a valuable 
substitute which will not become objectionable too soon, and 
will not require such enormous quantities of fluid as ordinary 
milk does. 

Drug treatment is purely symptomatic. Irritant diuretics 
aggravate the condition of the kidneys. The best diuretic in 
these cases is a saline, either potassium nitrate, citrate or ace- 
tate or lithium citrate. The natural lithia waters contain a large 
proportion of lime, which is contraindicated in senile cases. 
The general treatment suggested under chronic interstitial 
nephritis will apply to this disease. 

Pyelitis is rare, most cases being due to the irritation pro- 
duced by a renal calculus, followed by infection. Typhoid 
fever, which is a frequent cause of this condition, is rare in the 
aged and likewise tuberculosis and cancer of the kidney. The 
disease does not differ from pyelitis in earlier life and must be 
treated the same way. 

Renal and perirenal abscesses and cysts may occur, but the 
causes are rare and in their pathology, symptomatology and 
treatment do not differ from the same diseases in maturity. 

MYALGIA 

Myalgia, or muscular rheumatism, occurs frequently both 
in the acute and the chronic forms. 

Etiology. — The most frequent cause of myalgia is a sudden 
chilling of the surface especially when it had been overheated. 
It is probably due to the same toxins that produce fatigue, 
as it occurs most frequently in muscles which have been sub- 
jectd to extraordinary exercise or where, owing to poor surface 
circulation, a sudden chilling will still further interfere with the 



MYALGIA 469 

circulation and prevent the removal of the toxins produced by 
muscle activity. Myalgia pectoralis, pleurodynia, occurs fre- 
quently as the result of hard coughing or sneezing; myalgia 
lumhalis or lumbago occurs most frequently when the surface 
had been chilled; myalgia cervicalis, torticoUis, may be due to a 
draught or to extreme rotation of the head; myalgia capitis, 
cephalodynia or rheumatism of the scalp, is generally due to 
exposure when the scalp is warm, as for example when a person 
in a heated room puts his head out of a window during extremely 
cold weather. The dull ache of chronic or prolonged myalgia 
is identical with the pain in muscles that have been excessively 
exercised and the relief from these pains is brought about by 
measures best calculated to promote local circulation which 
would remove these toxins. There is no evidence that the 
disease is due to a bacterial infection, but causes that interfere 
with local circulation such as arteriosclerosis, or conditions 
interfering with the ability of the blood to carry away toxic 
material, as in the gouty diathesis, autointoxication, etc., pre- 
dispose to it. There is also probably a neuralgia or neuritis 
present, the initial symptom generally starting with a sharp 
neuralgic pain as in sciatica or in intercostal neuralgia, and 
this pain can be reproduced upon motion. 

Pathology. — No distinctive lesions have been found, the 
usual anatomical changes discoverable upon autopsy in cases 
where death had occurred from some other disease while a 
patient had an associated myalgia, being due to senile degenera- 
tion of the muscles and nerves. 

Symptoms. — The initial symptom is usually a sharp neu- 
ralgic pain w^hich is soon followed by a persistent dull ache 
aggravated upon motion. Some authors say the pain is in- 
creased upon pressure; others say pressure lessens the pain. 
Steady pressure -^dthout motion during the neuralgic stage 
lessens the pain, but during the later stage pressure increases 
the ache w^hile sudden motion will produce a sudden sharp pain 
resembling that of neuritis. The pain in the muscle may ex- 
tend to the tendons and aponeuroses. In some cases the initial 
pain lasts but a moment or may be absent altogether, in others 
there may be paroxysmal attacks even without motion. The 
dull myalgic ache is always present while the sharp neuralgic 
or neuritic pain is occasionally absent. The disease is usually 



470 PATHOLOGICAL OLD AGE 

unilateral, rarely extending beyond one muscle or group of 
muscles. The affected part is always held in a position causing 
the least strain upon the affected muscles, shielding them as 
far as possible from motion. While neuralgia is an important 
element in the diagnosis and treatment of myalgia, the recogni- 
tion of myositis is more important. Neuralgia is of short dura- 
tion; there is a painful point along the nerve, while the surround- 
ing tissue is not painful. In myalgia there is no painful point 
unless the accompanying neuralgia is persistent and severe; 
there is local tenderness, however, and the disease is prolonged. 
There should be no difficulty in differentiating between myalgia, 
myositis, pleurisy, spondylitis, costal caries, cancer, renal cal- 
culi, etc., which all give localized pain. The aches due to 
senile waste of muscle are increased upon motion, but there is 
no pain when the patient changes his position in bed. 

Treatment. — The treatment of myalgia consists of rest, heat 
and the avoidance of the cause. In pleurodynia it may be neces- 
sary to strap the affected side with strips of adhesive plaster to 
secure the necessary rest for the affected muscles. Heat should 
be applied in the shape of hot poultices, turpentine stupes or 
cataplasms. An inunction of equal parts of chloral and cam- 
phor or menthol and camphor will relieve the pain of the neu- 
ralgia and may relieve the myositis. Extremely hot baths, as 
the Turkish or Russian baths, are dangerous in old age. If 
the pain persists and is severe, it may be necessary to use hypo- 
dermics of morphine and atropin, but other internal medication 
is useless. The causative condition, if due to gout, autointoxi- 
cation, or similar endogenous factors, should be treated. 

Myositis, inflammation of muscles, is rare. A chronic fibrous 
myositis may occur as a manifestation of tertiary syphilis, while 
acute primary myositis is believed to be due to infection or 
fatigue toxins. The chronic form is an interstitial myositis, 
with proliferation of connective tissue and atrophy of the mus- 
cular fibers, the muscle mass appearing in some parts swollen, 
in other parts atrophied, in parts soft, in others firm. The 
disease spreads over large areas or is scattered over many mus- 
cles, there is a dull ache worse on motion or pressure and some- 
times worse at night. The symptoms are relieved by anti- 
syphilitic treatment. In the acute form there is rapid atrophy 
of the affected muscles partly through degeneration and partly 



m:6niere's symptom complex 471 

through pressure of round-celled proliferation of the connec- 
tive tissue. There is a gradually increasing pain in the muscles 
and progressive loss of power. The affected muscles are at 
first firm and apparently swollen, later they become thin and 
soft. The disease resembles myalgia, but the increasing pain, 
atrophy and loss of power should serve to distinguish it from 
the other. In rare cases there is fever and swelling and the 
disease resembles acute articular rheumatism, there is, however, 
no pain in the joint itself, while the muscle pain is constantly 
increasing, and muscles in other locations than over joints are 
also affected. 

Trichinosis gives symptoms similar to acute primary myositis. 

Examination of the blood shows an increase of eosinophiles, 
but a positive diagnosis can be made only by examining a 
piece of muscle under the microscope. In polyneuritis there are 
painful points or the pain is along the line of the nerve, the 
surface is tender and there is no atrophy of muscle. No treat- 
ment is known for myositis. The salicylates are of service 
if there is fever and narcotics may be required for the pain. 
The disease occasionally disappears without treatment. 

Progressive muscular atrophy is almost always the spinal 
form, which had been carried over as a very slowly progressing 
disease from maturity; it never originates in old age. The 
history and the symmetrical atrophy without sensory dis- 
turbance, diminished tendon reflex, fibrillary twitching, and 
absence of disttirbance in organs of spinal origin distinguish 
it from other diseases in which muscular atrophy is a prominent 
symptom. The disease is incurable and slowly progressive, 
and nothing is known to retard it. 

MENIERE'S SYMPTOM COMPLEX 

Meniere's disease of the labyrinth is extremely rare but the 
symptom complex with some modifications is of frequent 
occurrence in the aged. When due to other causes than disease 
of the labyrinth it is known as pseudo-meniere's disease. 

Etiology. — In a few cases the symptom complex is due to 
middle or inner ear affections. More often it follows a general 
disease such as syphilis, gout, diabetes, leukemia, general paresis, 
or may follow injury to the head or disease of the nose. It 



472 



PATHOLOGICAL OLD AGE 



may also occur in hysteria, neurasthenia and psychic disorders. 
The most frequent cause is arteriosclerosis of the vessels of the 
ear or brain. 

Symptoms. — The symptom complex consists of a paroxysmal 
rotary vertigo, generally so severe as to produce momentary 
unconsciousness, followed by headache and usually nausea 
and vomiting. Tinnitus and difficulty in hearing may precede 
but generally follow an attack. The vertigo generally lasts 
a few minutes, rarely over a quarter of an hour, but the headache 
and nausea may last for several hours, while the tinnitus and 
deafness may be permanent but varying in degree. If the 
vertigo is prolonged, ataxic symptoms appear, but these dis- 
appear as soon as vertigo passes away. The ear symptoms may 
appear on one side or on both sides. In some cases there is a 
persistent mild vertigo with sudden exacerbations, in other cases 
complete deafness occurs and all other symptoms disappear. 

Treatment. — The treatment depends upon the underlying 
condition. There is no known cure for the labyrinthine disease, 
but the symptoms usually disappear as soon as complete 
deafness occurs. When due to other causes the ctire of the 
primary condition will relieve the symptom complex. Large 
doses of the bromides will usually relieve the nausea, headache 
and other secondary reflex symptoms following the vertigo. 
The only relief of the vertigo is found in the recumbent posi- 
tion with the head low. 

OSTEOMALACIA 

Etiology. — Osteomalacia is probably due to some perversion 
in the function of the thyroid gland. The relation of the 
thyroid to metabolism is still somewhat uncertain and there 
seems to be a tendency to ascribe all trophic changes of unknown 
origin to thyroid disease. Osteomalacia has, however, been 
found most prevalent where goiter is endemic, and Grajon states 
that it is frequently found in the aged insane. 

Pathology. — The anatomical changes are a waste of cancel- 
lous structure and a resorption of lime salts, later the harder 
structure about the Haversian canals also soften. The perios- 
teum generally becomes thin and sometimes separates from 
the bone; in rare cases it becomes thicker. The medullary canal 
is increased in diameter and the marrow is at first red, later it 



OSTEOMALACIA 473 

becomes yellowish and gelatinous. The most marked changes 
are found in the spinal column. 

Symptoms. — The disease in the aged begins with persistent 
slight aches and pains, generally in the back and loins, sometimes 
in the extremities, and with increasing difficulty in motion. 
As the disease progresses the pains become more severe and 
motion is thereby restricted until finally the patient is confined 
to his bed avoiding the least possible change of position. Owing 
to the pain, the aged patient does not walk or stand much and 
the deformity in the lower limbs does not become as marked as 
in Paget's disease, but as he sits more there is a greater curvature 
of the spine consisting of both a scoliosis and a kyphosis with 
consequent malformation of the chest walls. This change and 
the compression of the pelvis, depression of the neck of the 
femur and curvature of the long bones of the lower extremities 
produce a marked diminution in a stature. In some cases 
the ribs reach the ilia. The least affected are the bones of the 
skull. As the disease advances mental depression ensues, the 
face becomes dull and expressionless. Later constitutional 
symptoms will appear such as anemia, antointoxication follow- 
ing constipation dyspnea and cyanosis, then cardiac and 
circulatory disturbance with trophic disorders in all organs and 
tissues. The diagnosis is difficult at an early stage of the 
disease and can only be made by excluding chronic rheumatism, 
gout and other arthritic diseases, syphilis, tumors, carcinoma, 
various neuralgias, tabes and other spinal affections. Syphilis 
is excluded by nocturnal exacerbations of pain by the history 
and by the result of treatment; rheumatism by its location in 
the joints; gout by the location and character of the pain. In 
these and other arthritic diseases the impairment of motion is 
due to a stiff erning of the joint, w^hile in osteomalacia impairment 
of motion is due to weakening of the bone. Tumors give local- 
ized symptoms and cancer can usually be diagnosed by the his- 
tory, the presence of cancer in other localities and the local 
and general symptoms. The neuralgias are localized and the 
pains are paroxysmal. Tabes has pathognomonic symptoms 
and signs and in other spinal diseases the pains are not diffuse, 
nor is there bone tenderness. Paget's disease is more localized, 
thse is a hyperplasia of bone, and pains, if present, are not 
severe. 



474 PATHOLOGICAL OLD AGE 

Treatment. — Phosphorus is virtually a specific in osteo- 
malacia. The rationale of this treatment lies in the property 
of phosphorus to combine with lime to form phosphate of lime 
which is deposted in the bones. The dose is i/ioo grain three 
times a day. It can also be given in the form of glycerophosphate 
of lime, but lime salts not in a phosphorus combination are not 
taken up in this disease. Dietetic and hygienic rules must be 
observed. Sulphur baths and massage may be employed, 
but exercise or any active motion is prohibited. Codliver oil 
has done good in some cases. 

Osteomyelitis is rare in the aged. Fatigue is believed to 
be an important etiological factor in senile cases and when it 
attacks an aged person it is generally after excessive walking, 
when the tibia will be found affected. In some cases no cause 
can be found. The symptoms are pronounced, the pain is 
intense and increasing in severity and the constitutional symp- 
toms of infection are grave. In a few cases mild symptoms 
prevail but the disease in the aged is usually fatal. 

Treatment is the same as in earlier life, but in the grave 
form operation alone offers any chance of recovery. 

SPINAL DISEASES 

Acute myelitis is rare in the aged, the principal etiological 
factors, toxins and infectious diseases being of infrequent 
occurrence. It does not differ from the acute myelitis of 
earlier life, presenting the same lesions and symptoms. It 
has a greater tendency though to become chronic. 

Chronic myelitis following the acute attacks is of short 
duration. In these cases vesical and intestinal paresis generally 
follow with consequent autointoxications, sepsis and exhaustion. 
This form of chronic myelitis differs from the senile myelitis 
in which there is a slow, progressive, but never complete, 
paraplegia, and the intestines and bladder are but slightly if 
at all involved. Treatment is the same as in earlier life. 

Compression myelitis is almost always due to veretbral 
caries or carcinoma. A very rare cause which does not prevail 
in earlier life is the compression produced by a beady hardening 
of the vertebral artery in arteriosclerosis of that vessel. The 
symptoms are the same as in maturity and depend upon the 
location of the lesion. The causes being persisting and in- 



"^«V/'^w^,W 



Tremorgraph — ^lultiple sclerosis. (Xeuslaed- 
ter, Med. Record, July 17, 1909.) 




Tremorgraph — ^Multiple sclerosis. (Neustaedter, 
Record, July 17, 1909.) 



Med. 



\j^\M I ' 



^ . ^ wiy^"' ^ > 



Tremorgraph — Dementia paralytica. (Neustaedter, Med. Record, July i 

1909.) 



CEREBRAL DISEASES 475 

creasing in force or extent, the symptoms also persist and 
usually become more intense or involve larger areas, and there 
are no remissions. The compression myelitis due to caries is 
slowly progressive and there is a dull ache. When due to 
cancer it is rapidly progressive with intense pain. 

The treatment depends upon the cause. Orthopedic ap- 
pliances are indicated in cases of caries without abscess. Tuber- 
culosis or syphilis when present must receive appropriate treat- 
ment. Cancer being usually a secondary condition following 
cancer in other tissues, nothing can be done except to relieve 
the symptoms. It may be necessary to resort to narcotics in 
such cases. Spinal diseases generally are rare in the aged and 
many degenerative changes which in earlier life give pronounced 
symptoms are found upon autopsy of aged persons, to have 
produced no symptoms of spinal affection during life. Clearly 
defined symptoms of tabes dorsalis, spastic spinal paralysis, 
multiple sclerosis, syringomyelis, etc., are very rarely observed 
after the sixtieth year, while the lesions themselves are not at 
all infrequent. The lesions of multiple sclerosis of the cord are 
frequently found after death and appear to be nothing more than 
the normal senile changes. It is only when these degenerative 
changes occur as a result of abnormal factors, such as syphilis, 
infectious disease, growths or traumatism that they present 
pronounced morbid symptoms. In senile cases the symptoms 
are generally milder and more prolonged than in matiuity but 
pain is more intense, while muscle rigidity and motor paralysis 
may proceed to complete loss of motor function. 

Cases of spinal disease may be carried over as chronic affec- 
tions from earlier life and, owing to more rest and better hy- 
gienic environment enjoyed by the aged, the symptoms may 
become milder. The degenerations, however, cannot be re- 
paired and are usually progressive. The treatment of spinal 
affections in the aged is the same as in younger individuals, 
care being taken in the selection of drugs to guard against 
secondary effects upon the heart and blood-vessels. This 
applies with special force to strychnine. 

CEREBRAL DISEASES 

Meningitis is very rare in the aged. Pachymeningitis 
interna may occur in cerebral atrophy but its symptoms are 



476 ' PATHOLOGICAL OLD AGE 

not clear. Paroxysmal attacks of headache, temporary at- 
tacks of hemiplegia, unilateral muscle cramps, and tempera- 
mental changes have been found in connection with it, but 
there is no pathognomonic sign or symptom complex. 

Purulent meningitis may occur with mastoiditis, otitis 
media, erysipelas and other infectious diseases. It begins with 
malaise, violent headache and other cerebral symptoms point- 
ing to meningitis. Rigidity of the muscles of the neck and ex- 
tremities occurs. The cranial nerves in the locality of the inflam- 
mation become involved and the functions of the parts supplied 
by them, are impaired. Kernig's sign is present. The reflexes 
are first exaggerated, later abolished. The presence of pus in 
the cerebrospinal fluid confirms the diagnosis. The ordinary 
treatment for meningitis, rest, quiet, ice bags to the head, 
narcotics, etc., apply to this condition. Serum therapy may 
be tried. Lumbar puncture gives temporary relief. 

Tubercular meningitis may occur in connection with pulmon- 
ary tuberculosis. The symptoms are the same as in purulent 
meningitis and the same local treatment is indicated. The 
underlying disease needs attention. Meningeal affections in 
the aged are usually secondary, run a chronic course and while 
incurable death in most cases is due to the underlying disease. 

Syphilis of the brain is very rare after the sixtieth year and 
unless there are gummata which produce cerebral compression, 
there are no clearly defined symptoms. 

Abscess of the brain is generally due to traumatism, occa- 
sionally to pyemia, rarely to infectious peritonitis, endocarditis 
or other infectious inflammation or to abscess or gangrene 
elsewhere. It does not differ from the same condition in earlier 
life. 



HOME CARE OF THE AGED 



The old man wants constant attention and needs constant 
care. When he begins to feel the weight of his limbs and the 
creaking of his joints, the growing weakness and the loss of 
virility, when he begins to notice the hundred and one indica- 
tions that betoken the advancing years, his whole being becomes 
wrapt up in himself. His thoughts turn toward death and 
his one aim is the preservation of life. From this moment he 
becomes an object for his solicitude. While the mind is still 
bright he notes the little aches and pains that accompany old 
age, and avoids every motion that might aggravate them, 
thereby losing the benefit of exercise. As the sense of taste 
diminishes, he wants sharper and more spicy food and with the 
loss of teeth he swallows the food in lumps. He avoids strain- 
ing at stool and becomes constipated, the feces remaining in the 
colonic pouch. He finds a little difficulty in voiding urine and 
he defers the act until the accumulated amount gives him 
distress and in the meantime dilatation of the bladder is pro- 
duced or increased. 

When the mind becomes impaired he neglects his person in 
every direction until he becomes obnoxious to those aroimd 
him. He cannot accommodate himself to a progressive order 
or to modern ideas, he becomes old fashioned, even queer, while 
those nearest to him try to humor his whims until patience is 
well-nigh exhausted. At the same time he demands constant 
attention and complains of the slightest neglect. The firm 
insistance upon hygienic measures for his benefit and welfare, 
which necessarily impose some exertion on his part, is resented 
as a hardship and creates a dislike of those who are most in- 
terested in his welfare. This is the foundation of oikiomania, 
the morbid state in which the natural love for those entitled to 
the love of the individual, is turned to hatred, without reason- 
able cause. As this is common among the aged who live with 
their family, it is the principal bar to the successful treatment of 

477 



478 HYGIENE IN OLD AGE 

diseases and the proper hygienic care of the aged at home. 
Rather than force the old man to take proper care of himself, 
and thereby incur his displeasure, they submit to his whims and 
permit him to deteriorate mentally and physically faster than 
he would under other circumstances. 

In many cases it is possible to overcome the prejudices of 
the aged by tact, and to create in them a sense of well-being. In 
the article on Senile Cachexia it was pointed out that many 
cases of decrepitude were really cases of pseudo- or psychic 
debility and that the removal of certain factors causing this 
pseudo- debility would rejuvenate the aged. 

Mental stimulation is the most important measure in the 
hygiene of the aged. Anything which will tend to make the 
senescent take an interest in life beyond their own little ego 
will benefit them. We may repeat here that the psychic in- 
fluence of flattery is more potent in arousing ambition than 
drugs or reasoning. It will arouse renewed pride in appearance 
which is usually lost when ambition is lost in the contemplation 
of death in the near future. 

Just as long as this pride in appearance is maintained, so 
long will the individual follow willingly the hygienic rules neces- 
sary for his welfare, even though it requires some exertion and 
effort to carry them out. Mental activity arouses physical 
activity and creates vigor if the organism is still in the condition 
to respond. The most powerful of the mental stimulants are, 
change of scene and residence, change in the mode of Hving, a 
young wife or husband, discussion upon some familiar favorite 
subject, or a hobby. The joke about the bald heads in the 
theater where there are pretty chorus girls has a psychological 
basis. Mental activity is aroused and the old man feels young 
again. Whatever the means may be, the end to be attained is 
the same, therefore, mental activity must be encouraged, and 
pride in personal appearance stimulated. If this much is ac- 
complished there will be little difficulty in dealing with the old. 

The other principal hygienic measures are food and exercise. 
Cleanliness and clothing are secondary, for notwithstanding the 
importance of cleanliness from an esthetic point of view, many 
reach advanced old age who have rarely taken a bath and who 
have had little choice in the selection of clothing. Fresh air is 
necessary and the air of the country is better than the air of the 



HOME CARE OF THE AGED 479 

city. Caution as to the evacuations seems superfluous, as this 
applies to all ages and to all conditions. Still the aged pay less 
attention to the stools and urine, especially if there is any diffi- 
culty in passing either, and this neglect causes pathological con- 
ditions. They should go to the toilet at the same hour each 
day and the family should not place too much reliance upon 
the patient's assurance that it is "all right." The family 
should attend to the cleansing of the catheter and the rectal 
tube if these are used, and they should be made sterile again 
just before they are to be employed. A daily bath entails too 
much exertion for the old man who has no attendant to help 
him in and out of the tub. A tepid bath once a week will 
accomplish all that is necessary in the case of the aged, but 
daily ablutions of the hands, face and neck should be insisted 
upon. The common laundry soap should not be used as it 
makes the skin excessively dry. Either a mild soap like castile 
soap or plain borax can be employed, and sea salt or common 
salt should be used for the bath. For the bromidrosis, washing 
with Florida water or cologne water and powdering the part 
with a mixture of stearate of zinc and salicylic acid will gener- 
ally relieve, and may cure, this condition. As the surface 
temperature of the body is generally low and the aged do not 
perspire readily they should wear warm woolens all the year 
round. In winter heavy imderwear will keep them warmer 
than a heavy overcoat and there is less weight to carry. The 
legs and feet should be especially looked after as the lessened 
surface sensibility makes the aged less sensitive to temperature 
changes, while the poorer surface circulation in the lower limbs 
makes them especially liable to chilblains, frost bites and 
frozen feet and toes. This is a frequent cause of senile gangrene. 
The same precaution need not be taken with the face but in 
very cold weather the ears should be protected. An important 
article of wear is the shoe, which should be selected ^dth due 
regard for corns, bunions, hammer-toes and broken-down 
arches. It should have rubber heels and arch supporters 
whether there are broken-down arches or not. Apparently 
insignificant, yet really of great importance, is the cane, upon 
which the old man depends for support when the senile kypho- 
sis and waste of the muscles of the back make him stoop. With 
the cane he is able to maintain a fairly erect position and if he 



480 HYGIENE IN OLD AGE 

uses it as soon as he begins to notice the tendency to stoop or 
to fall into the attitude of the senile slouch, he will keep erect 
and lessen the strain upon the back muscles and the compres- 
sion of the intervertebral discs. The cane should be sufficiently 
long so that when the point is on the ground at the distance of 
the ordinary step from the body, the user will not be obliged to 
stoop over when grasping the handle. Most canes are too 
short and the man must do the very thing the cane is intended 
to prevent. 

The diet of the aged must be regulated by the state of the 
teeth, stomach and intestines, and by the metabolic activity 
and assimilation. The senile organism requires less food, it 
can dispose of less food, and less is assimilated. Owing to the 
changes in the stomach, digestion is slower and weaker. With 
bad teeth the food is not properly masticated, consequently it 
is swallowed in lumps, which are digested with difficulty or not 
at all. Prosthesis can remedy this defect, and here again it is 
often necessary to play upon his pride in appearance to induce 
him to undergo the annoyance and sometimes positive distress 
connected with the making and wearing of artificial teeth. 
Women submit to these discomforts more readily than men, for 
their natural vanity induces them to appear attractive, even 
when extremely old. Gourmands who are accustomed to eat 
too much will not break themselves of the habit when they 
become old unless gastritis and diarrhea make a limited diet 
imperative. The oft-repeated advice that the aged should eat 
little and often is irrational, for digestion is naturally slower 
in old age and frequent feedings keep the stomach constantly 
at work, there being always a mass of food in the stomach in 
different stages of digestion. This is the most frequent cause 
of flatulence, heart burn and senile gastric catarrh with its 
attendant pyrosis and gastrodynia. 

In old age, food should be taken not oftener than once in 
five- or six-hour intervals at fixed hours each day. The number 
of meals, like the time of day when the principal meal is taken, 
is a matter of habit, often of nationality, and does not affect 
the rule. A few simple directions will serve better than any 
fixed diet list. 

If food cannot be masticated it should be chopped up fine 
or administered in the form of mush. No food should be taken 



HOME CARE OF THE AGED 48 1 

between meals. Milk, buttermilk, weak tea, coffee, strained 
cocoa, can be taken, however, preferably an hour after meals. 
Meat should be used sparingly, not oftener than once a day, 
preferably underdone. Pork is forbidden. Fish and shell fish 
may be taken if they do not produce ill effects but if they harm 
once, they will harm again. Vegetables containing much fiber 
like cabbage, turnips, carrots, sweet potatoes, etc., leave a large 
amount of waste and induce peristalsis. The cereals and the 
breakfast foods are all good. "Wine is the milk of the aged." 
Light wines like Hock, Moselle, Claret, Burgundy, etc., are the 
best. Port, old Sherry and Madeira wines contain too much 
alcohol. Beer and ale may be taken if they do not produce 
flatulence or pyrosis. The day should be begun with a glass of 
hot water containing a little table salt or if constipation exists 
a teaspoonful of any of the cathartic salts, and at night a glass 
of hot milk may be taken before going to bed. As the aged 
person is liable to awake during the night a glass of milk can be 
left at the bedside. Gastric and intestinal disorders may 
necessitate modification of these rules. A safe general rule is 
to avoid all purin-forming substances, foods containing much 
cellulose and foods containing a large percentage of water. 
This will hold good for all conditions. Not\^ithstanding all 
that has been said and written against drinking and smoking 
most men who have reached advanced age have indulged in 
both. Everything in excess is harmful. As for the determina- 
tion of what is excessive every man is his own judge. When a 
man has lived so rational a life that he has reached old age it 
can be safely left to his own judgment to decide how much he 
can drink and smoke mthout harm. 

The question of exercise is intimately bound up with mental 
stimulation. The aged need mental and physical exercise 
and recreation, the form of both depending upon the mental 
and physical condition of the individual and the proper applica- 
tion of the rtde that recreation should be the antithesis of the 
work necessitating it. Mental labor, requires physical recrea- 
tion, a sedentary occupation requires activity, etc. The same 
holds good for the aged but as all forms of activity are diminished 
and fatigue sets in more rapidly, exercise and recreation must 
be milder than in maturity. Physical activity cannot be pro- 
longed on account of the weakened locomotory tissues, these 
31 



482 HYGIENE IN OLD AGE 

soon becoming tired, also on account of the increased action of 
the heart and lungs which cannot keep up prolonged hyperac- 
tivity without increasing their own degeneration. Still, some 
form of exercise is necessary to prevent stiffening of the joints. 
It is hardly in place here to discuss the theoretical necessity 
of exercise to produce heat and increase metabolic activity. 
Joint motion must be undertaken to prevent anchylosis, even 
though it increases waste which is not repaired. The best form 
of exercise for the aged is walking up a slight incline with 
frequent rests. This exercises the muscles of the lower extremi- 
ties and of the back and if a cane is used, the muscles of the 
upper extremities are also brought into play. A walk through an 
unfamiliar forest path will not alone give physical exercise 
but will stimulate the brain and cause continual mental exhilara- 
tion. Nothing, however, equals a few hours of fishing when fish- 
ing is good. 

Active athletics are naturally out of the question, even 
gymnastics cannot be undertaken, but calisthenics are beneficial. 
An imperative rule in all forms of exercise in the aged is to 
stop the moment fatigue sets in or dyspnea or palpitation is 
produced. Mental stimulation cannot be continued beyond 
its physiological limit, for when brain fatigue sets in, the aged 
individual falls asleep. This is seen in the case of the old 
man who falls asleep during the sermon. It is not lack of 
attention but prolonged mental concentration that causes the 
brain fatigue and sleep. This should be understood by speakers 
who resent the seeming slight when an old person falls asleep 
dtiring a sermon or lecture. Even sensory stimulation can 
produce mental fatigue, as is seen when the aged fall asleep at 
the concert or spectacular play. Mental stimulation should 
be agreeable, otherwise it is mental irritation which is depress- 
ing. Discord in music, the whirl of the dance, the shouting 
at a game irritate, while melody, the harmonious movements 
of the ballet, catchy songs sung by a chorus, stimulate and 
create cheerfulness. The play which demands constant atten- 
tion to understand the slow unraveling of the plot is wasted 
upon the old man, and also the play which is complicated or 
where the action is so rapid that the mind cannot follow it. 
The selection of the play, concert or similar diversion depends 
upon individual taste, but the mental capacity should not be 



HOME CARE OF THE AGED 483 

overlooked. The outing is an agreeable form of diversion, 
especially if young people take part and do not neglect the aged. 
If the old man likes fishing and hunting he may indulge in these 
pastimes, but rowing is too strenuous. 

Travel or a change of scene has often a wonderful effect 
upon the mind of the aged. If accustomed to the lowlands or 
seashore it is dangerous to take him to high altitudes. With 
this precaution, the destination should be a place in which he 
is interested and which he has not seen before, or not in years. 
The object should always be, to arouse in him an interest in 
something else than his body. A favorite pastime of old people 
consists in reading old familiar books, and in gossip. The 
old man's gossip is mostly reminiscences, the old woman's 
does not differ from the gossip of her younger days. 

The woman shows herein the greater interest in life, for 
she is interested in the doings of her sisters while the old man's 
talk begins with "I" and ends with "me." But even that is 
better than the reading of old books, because he has listeners 
who in turn tell their tales of ' ' I " and ' ' me ' ' and so create new 
interests. 

There are many little factors in and about the house which 
can be included in the hygiene of old age. The old man should 
have an easy chair with padded arm rests. Without such rests 
his hands lie in his lap and his shoulders fall closer together. 

With his arms on the rests his shoulders are thrown back, the 
upper part of his chest is expanded giving more room for the 
expansion of the lungs and he breathes deeper and more freely. 
If the chair is slightly tilted w^hen he takes his nap his head 
will fall backward and he will snore. If his head falls forward 
the vessels of the neck are compressed, which produces a passive 
cerebral hyperemia, as is evidenced by the flushed face and 
injected conjunctivae when he awakes. Let the old man 
snore, but if he groans w^hile sleeping with his head upon his 
chest, he should be awakened. Deafness and presbyopia are 
common ailments and the former, especially, causes mental 
depression and may lead to oikiomania and melancholia. 
The old are selfish and suspicious, they feel they are practically 
useless, that they are a burden upon those who look after them. 
When they cannot hear what is said around them, a glance in 
their direction is sufficient to arouse in them the suspicion that 



484 HYGIENE IN OLD AGE 

they are the subject of a conversation held in their presence, 
and such suspicions invariably lead to perverted conclusions. 
To avoid this, as soon as it is noticed that an aged person makes 
an effort to hear what is said, that he turns one ear to the speaker 
or watches the movements of the lips, or gives other evidence 
that hearing is becoming impaired, he should be furnished with 
a speaking tube or other appliance to improve his hearing. 

Drugs are useless. If the sight is impaired the nature of 
the impairment should be ascertained. In most cases it is 
simply a presbyopia which can be remedied by proper glasses. 
It may be cataract or a progressive amaurosis probably due 
to senile degeneration of the optic nerve. 

The aged are grateful for little attentions, such as an occa- 
sional nosegay, but if given for several days in succession they 
expect them and a single neglect to furnish them is cause for 
complaint. The memory of such neglect is hoarded and 
brooded over for days. If the old man or woman has a harmless 
hobby which is not silly and will not expose the individual to 
ridicule or interference, it should be encouraged. Unfortunately 
the hobbies of the aged are not always harmless, they are often 
childish, sometimes insane. It is extremely difficult to break 
an old person of a new hobby, especially if it involves sexual 
perversion or other moral defect. As the moral sense becomes 
blunted he cannot be made to realize the wrong in his actions 
and it may become necessary to instil fear of punishment to 
hold him in check. As the mental and physical powers wane, 
the aged find comfort in the association with children, especially 
in the companionship of a favorite grandchild or niece. Much 
can be done with them through the influence of such favorite 
child, and such companionship should be fostered. The wide- 
spread belief that the aged regain youthful vigor at the expense 
of the child has nothing to uphold it. 

The family should be taught to observe slight changes 
in the physical condition and demeanor of the aged under their 
care. The symptoms of disease begin so insidiously and pro- 
gress so mildly that a grave disease may be far advanced before 
the family realizes that the patient is ill. The aged seldom 
complain of pain or give other marked symptoms of disease, 
the mind and the perception of pain being blunted and it 
frequently happens that the earliest manifestation of the 



HOME CARE OF THE AGED 485 

disease is collapse. When an aged individual who is accus- 
tomed to be up and around shows a disinclination to leave his 
bed, it indicates a rapidly growing weakness such as accompanies 
senile pneumonia. The family says he is failing rapidly while 
it may be the exhaustion which accompanies a grave, probably 
a fatal, disease. When the aged individual talks in his sleep, 
and has never before done this, we have probably a low mutter- 
ing delirium indicating a cerebral disorder. The family should 
learn that a cool forehead may exist with high fever, that surface 
temperature is no indication of body temperature. A chill is 
always a signal of danger requiring immediate attention. Vom- 
iting after a heavy meal is often the first sign of acute gastritis 
which is always a grave disease in the aged. If he is too 
long in the toilet he may have fallen asleep or he may be 
straining to relieve a distended bladder which is blocked by a 
calculus or a hypertrophied prostate. A cold sweat on a pale 
face is a grave symptom generally indicating collapse. There are 
many causes for coma but when occurring in old age only that 
of apoplexy and embolism is sudden and without antecedent rec- 
ognized chronic disease. If the face is flushed, the head should 
be raised and ice bags applied. If the face is pale, hot applica- 
tions should be placed upon the head while the patient lies on 
his back with the head low. The same rule holds good if there 
is headache. Anorexia is not a dangerous symptom by itself 
and is frequently due to gastric catarrh. If there are other 
symptoms not pointing to gastric disorder, there is probably 
some serious disease present, anorexia being one of the earliest 
symptoms of inflammatory conditions. vSudden irritability in- 
dicates either mental disorder or distress, perhaps not amount- 
ing to pain. If the patient, complains of pain anywhere it 
should receive immediate attention. Occasionally the aged will 
complain of pain to arouse sympathy. It is difficult to detect 
such malingerers, especially if they refer the pain to some 
internal organ. Repeated examinations may be necessary, 
but the individual generally betrays himself by forgetting the 
spot where he located the pain at the former examination. 

INSTITUTIONAL CARE OF THE AGED 

What has been said in the preceding chapter applies to a 
great extent to the care of the aged in asylums. There is, 



486 HYGIENE IN OLD AGE 

however, a vast difference between the asylum and the home, 
and between asylums among themselves, and the care bestowed 
upon their inmates. There are private asylums, sectarian and 
unsectarian, to which a large admission fee is paid, private 
asylums maintained by organizations for their members who 
have contributed toward them and hence have a proprietary 
right to them, semi-private asylums maintained by nation- 
alities, churches and vocations for those of the same nation- 
ality, church or vocation, and public asylums or poor-houses. 
The care bestowed upon the inmates naturally depends upon 
the class of institution. Those who pay large admission fees 
belong to a strata of society in which refinement in surrotmd- 
ings is imperative, luxuries are necessities and the utmost care 
is expected. At the other extremity is the poor-house, the 
inmates of which are paupers from the slums of the city and the 
poorest inhabitants of the country. One fundamental differ- 
ence between the aged at home and in the asylum is in the 
mental attitude. In the asylum there is freedom from care 
about the future, from worry about the family to whom the 
individual had probably been a burden, and from fear that the 
family is trying to get rid of him and might go to extreme 
measures to sectire relief from the incubus. There is on the 
other hand the feeling of dependence and a sense of lost inde- 
pendence, restrictions in many directions, in actions, in food, 
perhaps in clothes, the inmate must obey rules, perform tasks, 
and above all he must not complain. In the public asylums 
there is a sense of absolute helplessness, the inmate feels that 
he is dependent upon the bounty of every individual in the 
community, that complaint will be followed by punishment, 
that he is virtually a beggar without rights. Under such cir- 
cumstances the inmates of alms-houses become morose, apa- 
thetic, they lose interest in everything except themselves, and 
melancholia and senile dementia follow. It is impossible to 
arouse in them any sense of pride in appearance, any ambition, 
or interest in anything. 

In New York City the name alms-house has been changed to 
City Home for the Aged and Infirm. This has had an elevat- 
ing influence upon the inmates who are now no longer paupers 
of the alms-house, but inmates of the city home. The estab- 
lishment of the city farms for them has had a further beneficial 



INSTITUTIONAL CARE OF THE AGED 487 

effect in stimulating interest — the great desideratum in dealing 
with the aged. In a great public institution intended for all 
races, religions and nationalities, the inmates form sets and 
cliques based upon similarity in race, religion or nationality 
and this gives rise to jealousies and ill-will. The inmates being 
drawn mainly from the lowest strata of society, they comprise 
the quizzical and querulous, the shrinking and the defying, the 
meek and the humble, and the dominating spirits found in the 
slum sections of the cities, and harshness is often necessary to 
enforce order among them. With such characters kindness is 
construed into weakness and it requires tact, patience and 
firmness to prevent excesses, especially if crippled and aged 
are thrown promiscuously together. The leaders in com- 
plaints and demands are generally the cripples who, being men- 
tally brighter than the aged succeed in securing better treatment, 
often better food than the others. In institutions where the 
aged have light tasks assigned to them they do not break down 
mentally either as soon or as completely as where the aged have 
nothing to do but sit on a bench and brood. In the large state 
institution at Lainz near Vienna, which the author visited, the 
inmates receive counters representing money which can be 
exchanged at a canteen on the grotmds for beer, tobacco and 
other little luxuries. In this way they receive a few cents each 
day and a certain amount of beer or tobacco. To prevent the 
ennui which leads to melancholia, the inmates follow their 
vocations in the institution, as far as they are able, and go 
twice daily to the canteen which is fitted up as a ''bier stube." 
They have a band, and in other ways their interest in life is 
maintained. They are naturally under restrictions, but they 
are at liberty to go and come at will within certain hours, and 
the depressing idea that they are paupers is not forced upon 
them. 

The care of the aged in public institutions depends as much 
upon the intelligence, tact and humanity of the person in charge 
as upon the funds at his disposal. It is naturally impossible to 
give individual attention to each inmate where there are many, 
but it is possible to stimulate individual interest in each one's 
welfare. It is likewise possible to make the inmates more 
cheerful, rouse them out of the lethargy into which newcomers 
soon sink, and prolong their lives. The aged like attention, 



488 HYGIENE IN OLD AGE 

but they do not like the attention of the sightseer who views 
them as curiosities. Neither do they want the patronizing and 
pitying expressions of sympathy from the philanthropists who 
give nothing else but sympathy. These two classes should be 
excluded from the public institutions. Inmates who do no work 
need no recreation and they do not want any. Work, however, 
stimulates the mind and body and recreation is then appre- 
ciated. The women should look after their rooms and be per- 
mitted to do such work as they are able to do in the kitchen, 
and they should be given the opportunity to do needle work 
which can be sold and part of the proceeds be turned over to 
them. Even the pauper in the alms-house feels that he is not 
absolutely worthless if he can do something and receive pay for 
his work. It need not be much, a few cents a day which the 
individual can call his or her own, will siiffice. The sense of 
proprietorship if only of a few cents arouses the self-respect 
that is crushed under the depressing feeling that one is a pauper. 
This was demonstrated to the author in his visit to the Austrian 
institution. 

The medical care of the aged in the public institutions 
should receive the same attention as in the public hospitals. 
In an asylum in New York city the vnndows of the dormitory 
were left open all day, while the bedding was turned back over 
the foot of the bed to permit both the bed and bedding to be 
thoroughly aired. At night the windows were closed, the heat 
turned on, and the bedding properly arranged for the night. 
The beds were cold when the inmates retired and the old people 
were chilled. Those that had bronchitis at once gave evidence 
of it and their coughing kept those awake who had no such 
disease. It is impossible to sleep in a cold bed until the heat of 
the body has warmed the bed sufficiently to keep the sleeper 
comfortable. The aged have a lower surface temperature, 
radiation is less active and it takes much longer to warm the 
bed by the body of an old person than it does by that of a 
younger and more active individual. This contributed to keep 
the old people in the institution awake for several hours after 
they went to bed, and could have been avoided by warming the 
bed before they occupied it. 

Social intercourse between the sexes should be permitted. 
To keep them apart, as is usually done, deprives them of one 



INSTITUTIONAL CARE OF THE AGED 489 

of the main sources of pleasure that they had before entering 
the institution. No good reason has ever been given why they 
should be kept apart. Even in semi-private and private homes 
this segregation is maintained, yet in some places where this 
barrier is removed the inmates form a large family party and 
greater interest is shown in the home and in each other. 

Too much stress cannot be laid upon the necessity for mental 
and physical employment in all classes of institutions, and for 
both sexes. There should be some system in the distribution 
of labor, and the work must be of such a nattue that sudden 
and prolonged intermission will not destroy it, and another 
person can take it up where one drops it. The aged delight 
in completed tasks and they are stimulated to further efforts. 
The work therefore should be light and of such a character that 
it can be completed in a few days or weeks; it should offer a 
variation so as not to become monotonous, and there should 
be no element of danger connected with it. Farm work is hard 
yet there are many light tasks about the farm which meet all 
the requirements of physical labor for the aged. Gardening, 
especially the care of potted plants, is an agreeable occupation 
for the aged, and a little commendation for their work incites 
them to continued efforts. It is, however, not advisable to 
create rivalry among the inmates of a home in tasks the out- 
come of which is beyond their control, as in the gro\\dng of plants. 

The recreations of the inmates of homes depend upon their 
mental and physical capacity and the character of the work 
which requires recreation. The depressing influence of the 
public alms-house causes rapid mental and ph^^sical deteriora- 
tion and the inmates seek few recreations. They should be 
supplied mth work and diversions. Those who can play a 
musical instrument should be given the opportunity to do so. 
There is no better collective recreation than an orchestra com- 
posed of inmates and concerts given by them. Dancing and 
athletics are dangerous, but social parties, masquerades, out- 
ings, etc., are harmless and agreeable. Such diversions involve 
little expense, yet this little is given grudgingly or not at all by 
communities that see in the aged paupers only economically 
worthless burdens. 

The favorite pastime of the aged is gossip. This does no 
harm. When they take up reading it is either something of 



490 HYGIENE IN OLD AGE 

a religious character or some favorite work that they had read 
and re-read over and over. They picture anew the scenes 
described and live again in the world of yesterday. Even 
this is better than no reading at all, although it does not arouse 
the same mental activity as a new book. There will always 
be found some inmates of homes who keep up their interest 
in the world of to-day, in the passing events, new books, art, 
and science. Such inmates shoiild receive every opportunity 
to improve their minds. The newspapers and popular magazines 
are better than novels, as they do not require prolonged and 
concentrated interest. Card playing is a simple pastime, the 
simpler games which require no mental effort being extremely 
popular in institutions where this pastime is permitted. Lotto, 
checkers and the various home games in which the chance 
fall of the dice determines the issue, all keep the mind engaged 
without involving strain or prolonged attention. 

In public institutions individual likes and dislikes are 
disregarded. It is naturally impossible to conform to the 
desires of each inmate, but in many instances concessions can 
be made, especially in relation to food, that may lengthen the 
life of the individual and make him happier. A Jewish inmate 
of a public (non-sectarian) institution would not eat certain 
articles of food proscribed by his faith and as he could get no 
other food, he became weakened from insufficient nutrition. 
He was removed to an institution of his own faith and rapidly 
gained in weight and strength. The remarkable showing of 
the Jewish homes for the aged is probably due to the greater 
care bestowed upon the food, especially upon the meats. 
(Longevity among Jews in spite of unsanitary surroundings is 
believed to be due to their sobriety and sanitary regulations 
regarding food.) It is impossible to arrange a diet list which 
would be generally applicable to all classes of institutions or 
even to all the inmates of one class. The general dietetic rules 
given in the last chapter will apply here, but there are naturally 
many exceptions. A different diet is necessary for those who 
have no teeth from the diet of those who can chew their food. 
As constipation is a common complaint among the aged, foods 
having this tendency should be avoided. These include fresh 
bread, eggs, liver, pork, rice pudding, sago pudding, milk, nuts, 
cheese and preserved (salt, potted or smoked) meats and fish. 



INSTITUTIONAL CARE OF THE AGED 49 1 

A pernicious practice which the author found in vogue in one 
institution was the addition of a cathartic to some article of 
food once a week. Drugs should not be given indiscriminately, 
but each case should receive individual care. Bladder and 
intestinal troubles are common among the inmates of institu- 
tions and they are generally due to neglect, occasionally to 
inadequate toilet arrangements. An apparently insignificant 
omission in one institution caused the inmates much annoyance. 
They were not permitted to go barefoot, there was no carpet 
on the floor of the hall and the toilet was at one corner. Several 
of the inmates were suffering from dilatation of the bladder and 
walking in their shoes on the bare floor at night disturbed the 
whole dormitory. A strip of carpet removed this source of 
insomnia. Where a large number of aged individuals are 
collected, daily baths, either tub or shower, become necessary. 
Constant vigilance is required to prevent an invasion of para- 
sites, for once they gain a foothold it may become necessary 
to quarantine the whole institution, giving the inmates their 
freedom, one by one, after each had been subjected to a steriliz- 
ing process or bath. The bath is also necessary on account of 
the bromidrosis common among the aged and which they do 
not perceive owing to the impairment of their olfactory organs. 

A distinctive costume is as humiliating to the pauper as it 
is to the prisoner and it crushes self-respect more certainly 
than the prison stripes. Throughout this work stress has been 
laid upon psychic influence upon the organism and the sense of 
well-being of the aged. If we wish to improve the sense of 
well-being that conduces to happiness, we must avoid depress- 
ing influences and especially such that mortify and humiliate 
the aged. Such humiliation and the sense of inability to repair 
the cause, or attack the offender, destroy what little dignity 
and self-esteem the individual has left after accepting the 
bitter bread of charity. This soon leads to melancholia and 
dementia. The only advantage in having uniform costumes 
of a distinctive pattern is to make supervision simpler; possibly, 
too, there is a slight saving in the expense of clothing the inmates. 
Neither advantage is comparable to the advantage derived 
by the inmates from the knowledge that they are not obliged 
to wear the costume of the pauper. 

In homes holding a large number of inmates, those having 



492 HYGIENE IN OLD AGE 

marked mental deterioration shotdd be removed from the others. 
As age advances many individuals become imitative like 
children and they are likely to imitate the actions and talk of 
the dullest of the inmates. Others become depressed when 
they are compelled to associate with dements, and may become 
likewise affected. 

Many find in religion the consolation that makes them 
resigned to the inevitable. Aged women are especially amenable 
to religious influences and ministers of the Gospel find no more 
grateful subjects than the inmates of homes for aged women. 
Every opportunity should be given the inmates to worship 
according to their own faith and while it may not be pra.cticable 
to have a separate chapel for each sect, where there is but one 
chapel it can be so fitted up that it will meet the requirements 
of the two great branches of Christianity, worshipping at 
different hours. Hebrews will not worship in a Christian chapel, 
but if there are many of that faith in a public non-sectarian 
institution any room can be converted into a temporary syna- 
gogue in a few minutes and at little expense. The head of such 
an institution, accustomed to handle all faiths and sects, will 
know the fast days and feast days of the Catholics, the 
Passover, the day of Atonement and other fast days of the 
Hebrews and other holidays kept by other faiths. The most 
important regulations to be observed on such days relate to 
food. If the head of such institution is ignorant of them, he 
can call to his aid either a well-informed inmate or a priest, 
minister or rabbi who will gladly advise him. 

In all homes for the aged, except the alms-houses, there is 
a community of interest ; it may be of religion or nationality or 
vocation, which binds all to a common object. There is also a 
sense of proprietary interest in the vocational, organization and 
private homes, which raises the inmates out of the class of 
paupers and dependents and entitles them to privileges and care 
which those in the alms-house have no right to demand. In 
the free homes maintained for certain nationalities and sects, 
the inmates are dependents but little better than paupers, and 
while the surroundings are far superior to the surroundings in 
the alms-house and the care is better, the inmates are still under 
the depressing influence of the sense of dependence upon the 
bounty of others. If we wish to increase the feeling of well- 



INSTITUTIONAL CARE OF THE AGED 493 

being in the aged we must remove depressing influences. To 
the sensitive person the idea of being dependent upon charity 
is most humiliating, and if this idea is being constantly kept 
before the individual it will produce melancholia and it has led 
to suicide. For this reason let me repeat, the sight-seer and the 
professional sympathizer should be kept out of such institutions 
and the inmates should be allowed slight liberties, such as to 
go and come at will within certain hours, receive visitors, do 
work which will not interfere with the orderly conduct of the 
asylum, receive pay for such work and spend their earnings. 
At the same time rules relating to the introduction of unsuitable 
food and drink should be rigidly enforced even to the extent of 
expulsion of an inmate who brings in such articles surreptitiously. 

Institutions of this kind often receive gifts of clothing. If 
worn clothing is received, it should be disinfected before distri- 
bution and the distribution should be made individually and in 
private, not as a public exhibition. 

The vocational homes are generally homes of vocational 
organizations toward the maintenance of w^hich the inmates 
have contributed, or else homes under government supervision 
for those who have been engaged in hazardous government 
occupations, and are offered as an inducement and prospective 
reward to those engaging in such work. A few vocational homes 
were founded by individual bequest and these are so well 
endowed that nothing is lacking to make the inmates contented 
and supply them with everything that can contribute to their 
welfare. The government asylums are mainly for soldiers and 
sailors, men accustomed to government routine and control 
and unaccustomed to home influences. These men can readily 
accommodate themselves to the new conditions and are not sub- 
jected to the mental depression associated with the idea of 
dependence upon charity. There is no such revolutionary 
change in their mode of life upon entering a government home as 
occurs in the life of the private individual who leaves his own 
home and family to enter an asylum. The vocational homes 
maintained by vocational organizations are like the homes 
maintained by fraternal organizations, private institutions 
to which the inmates have a certain proprietary right. Most 
organization asylums admit both sexes and thereby make 
institutional life more agreeable. To the old man or woman 



494 HYGIENE IN OLD AGE 

accustomed to associate with the opposite sex, the sudden and 
complete deprivation of such association must produce a 
profound change in the mental attitude. If, in addition thereto, 
there is a change in the home surroundings and in the mode of 
living, the temperament of the indi\'idual becomes altered. 
This is a common obser^'ation in homes for the aged. The 
inmate soon after admission improves mentally and physically 
through the freedom from care, changed surroundings and a 
more regular mode of life. After a few weeks a temperamental 
change is noted and this depends upon the difference between 
the new mode of life and the life to which he had been ac- 
customed. In a small house where the sexes mingle, as in the 
Actors' Fund Home on Staten Island, New York, the inmates 
form a large family. They occupy a cottage-like building which 
is to them a real home, not an asylimi or an institution. They 
find here an approach to home conditions under probably more 
wholesome surroundings than formerly, with freedom from care 
about the future. This is an ideal home for the aged. The 
cottage plan of housing the old has received but little attention 
in this coimtr^^ although the results obtained in the few smaU 
institutions occup3dng homelike cottages ought to commend it 
to those interested in the welfare of the aged. Where the 
cottage plan is impracticable, an effort should be made to copy 
home life as far as possible, by ha\'ing small sleeping rooms 
instead of large dormitories, permitting aged couples to remain 
together, and fitting up their room with pictures and decorations 
from their old home, observring of course sanitary precautions. 
True, such an arrangement may give sleeping rooms a bizarre 
appearance and detract from the sense of order and neatness; 
it will, however, conduce to the happiness of the indi\4dual and 
may arouse worthy emulation and rivalry among the inmates. 
The object is, after all, to increase the happiness and prolong 
the fives of the aged persons by making them feel as much "at 
home" as is possible under institutional conditions and by 
preventing and reHeving the fittle ailments which embitter and 
shorten their lives. 

In aU homes for the aged, music is the most acceptable and 
probably the most beneficial diversion. Even in the alms-house 
inmates will often be found who can play a musical instnmient 
and who would gladly join an orchestra composed of inmates. 



INSTITUTIONAL CARE OF THE AGED 495 

In such a nondescript orchestra it is not expected that the broken- 
winded trombone player will go through a Wagnerian opera 
or the tremulous fingers of the aged violinist will do justice 
to a nocturne. The aged prefer melody to harmony, and the 
old-time airs — which stimulate memory — to the airs of to-day. 
Not infrequently an old familiar air will rouse an individual 
from apathy and stimulate interest in life. To see an old 
pianist surrounded by a group of aged persons who are trying 
to sing in unison some sentimental song of a generation ago is a 
pathetic sight to the on-looker, but to the singers it means 
pleasure and happiness. In many other ways can the pleasures 
and happiness of the aged in institutions be enhanced. Men 
should be permitted to smoke in the open, but not in closed 
rooms; to play cards and other games, but not such as require 
much mental concentration or involve sudden exciting moments ; 
harmless hobbies should not be interfered with, and little pec- 
cadilloes should be condoned. At no time in life does the 
vanity of women appear more silly than in old age; yet the 
vanity of the aged woman shown in an effort to appear younger 
and more charming is an indication of her interest in life. 
Instead of being condemned, this vanity or pride in appearance 
should be encouraged. The use of cosmetics does no harm nor 
does any harm result from her efforts to dress in the prevailing 
fashion. Flattery is as agreeable to the woman of seventy as 
to the girl of seventeen and is more beneficial. Care in dress 
and order in the room should be rigidly enforced, while increas- 
ing disorder in dress, appearance or surroundings should be 
looked upon as a gradual weakening of the emotions and of the 
mind as a whole. 

The general lack of interest in geriatrics is responsible for 
the general neglect of the minor ailments of the aged. Some of 
these ailments have a pernicious psychic reaction, leading to 
delusions, which, with the increasing mental weakness, form senile 
paranoia. Presbyopia is generally neglected, little attention is 
paid to the teeth, virtually no attention is given to broken-down 
arches, or corns, bunions, and other pedal defects. The old 
man complains of pains and aches and they are set down as 
"rheumatic;" it is taken for granted that the old man will be 
constipated, and must urinate frequently ; that the aged woman 
will have varicose veins and perhaps chronic ulcers on the legs, 



496 HYGIENE IN OLD AGE 

intertrigo under the breasts, etc. Senile emphysema, senile 
tremor, senile debility, are dismissed with the remark ''old age," 
and nothing more is done for the sufferer. 

Senility is a state of physiological valetudinarianism. It 
requires special study, not as a pathological condition of ma- 
turity, but as an entity entirely apart from maturity and the 
person having charge of an institution for the aged should have 
the knowledge that comes from such study. This applies just 
as well to the physician who treats the ailments of the aged. 



MEDICO-LEGAL RELATIONS 



The most important and most frequent legal questions 
arising in connection with senility relate to the mental condi- 
tion of the individual when making a will. It is recognized 
that old age carries with it mental impairment. Mental im- 
pairment is part of the organic and functional changes that 
constitute ageing, it is progressive, there are no remissions and 
it terminates in complete obliteration of the intellect. Long 
before this, the reasoning faculty and judgment become so 
impaired that the individual does not comprehend the nature 
of his acts, while memory is so weakened that he does not know 
the extent of his property or those who have natural claims 
upon him. 

The mental functions and faculties do not become weakened 
uniformly and we consequently find some faculties stronger 
than others. Thus reason may be apparently as strong as in 
maturity yet memory and volition profoundly weakened. If 
there is a delusion, illusion or hallucination present, we have a 
form of insanity to deal with, a different proposition from the 
question of senile mental impairment. 

It has been held that testamentary capacity is destroyed 
by actual weakness of the mind, "by anything that will weaken 
the individual's memory, judgment and volition in relation to 
the disposal of his property or the objects of his bounty." This 
might be made to include slight impairment, not sufficiently 
marked to attract the attention of the stranger who is not 
familiar with the normal mental condition of the individual. 
In another decision the judge declared, ''the rule is that to 
avoid an instrument on the ground of the alleged mental inca- 
pacity of the person who executed the same, such person must 
have been so deprived of his mental faculties as to be wholly 
unable to understand or comprehend the nature of the trans- 
action." Other decisions place other constructions upon the 
condition of mind necessary to indicate testamentary capacity. 
When memory has become so defective that the aged individual 
32 497 



498 MEDICO-LEGAL RELATIONS 

does not know the extent of his property or the persons who have 
a nattiral claim upon it, or judgment is so weakened that he 
cannot intelligently dispose of it, his mental condition has 
passed beyond simple impairment; it is now senile dementia. 
There is no unanimity in either the medical or legal conception 
of the term "senile dementia." It has been applied to as slight 
an impairment as weakened memory alone. Some apply the 
term to that stage of impairment where the natural inhibition 
upon conduct is diminished or lost ; some will not declare a case 
to be senile dementia until it has reached a stage where it 
becomes obvious to others who do not know the normal mental 
condition of the individual, while some authorities say mental 
derangement must accompany mental weakness. This last 
conception is wrong, for in many cases there is a gradual dulling 
of the faculties, an increasing difficulty in recalling events, in 
concentrating attention, in reasoning, in controlling the emo- 
tions, yet without mental perversion. If such an individual 
performs an irrational act it is through thoughtlessness, lack of 
reflection or impulse and not through illusions, delusions or 
hallucinations. In mental derangement the individual performs 
irrational acts because he thinks they are right. He is con- 
scious that he has performed certain acts but his views concern- 
ing them are based upon false conception or belief or false per- 
ception with or without material basis and he will not accept 
rational views. The senile dement performs his acts without 
false conception or perception but rather unconsciously or im- 
pulsively and if any impression can be made upon his reasoning 
power if he can be sufficiently roused to realize that he has 
performed an act, he will recognize its sense or folly. It may 
be that owing to the frequent repetition of a story it may finally 
impress itself so vividly upon the mind as to produce therein 
the idea of reality and thus become a fixed delusion, but this 
in itself would not be a mental derangement. In old age the 
moral sense is frequently blunted and the lessened control over 
conduct may give rise to acts of immorality. In the popular 
conception of the term insanity these may be called insane acts, 
they are, however, not due to mental derangement but to men- 
tal and moral weakness. A distinction is to be made between 
mental derangement and mental impairment, although both 
may exist at the same time. 



MEDICO-LEGAL RELATIONS 499 

It has been held that forgetfulness of recent events is no 
evidence of incapacity to make a will. Forgetting the name 
of a member of the family does not imply such extensive mental 
impairment as to incapacitate the individual, but to forget the 
existence of a member of a family, especially if the person for- 
gotten has not been absent sufficiently long to explain such for- 
getfulness, denotes profound mental weakness. It is always 
difficult to determine whether the omission from the provisions 
of a will of one having a natural claim upon the testator was 
intention or the result of defective memory. Occasional 
absent-mindedness due to mental concentration is no evidence 
of mental weakness, but persistent absent-mindedness or day 
dreaming, not due to mental concentration, shows profound 
mental impairment. To what extent this would affect the 
judgment of the individual while drawing up a will will depend 
upon his condition at the time. It is sometimes possible to 
arouse mental activity temporarily and maintain prolonged 
attention, under special stimulus, as when in danger or when 
facing some grave responsibility. Under such circumstances 
the individual would be in the same mental condition as dur- 
ing the lucid interval of paresis. 

Judgment may be impaired in certain directions without 
affecting the disposing capacity, as where peculiarities and idio- 
syncrasies exist which do not impair the individual's memory 
or judgment as to the extent of his property and his obligations 
to his family. Hamilton says ''the senile dement is prone to 
make foolish and trivial disposition of his property and par- 
ticularly is this the case when he is aided by designing people 
who siuTOund him, and the individual of this kind is very apt to 
be easily turned from his original piu-pose by fresh suggestions 
or new influences. He is liable to imposition and unjustifiable 
prejudice." The question of senile dementia depends upon the 
questioner's conception of the extent of the individual's mental 
impairment, evidenced by weakened memory, reasoning power 
and volition, as compared with the mental condition of the 
individual when at its best. In determining the extent of im- 
pairment it is necessary to compare all the faculties \\dth the 
faculties as they were and not with the faculties of another of 
the same age. It is necessary to determine the form of demen- 
tia. The dementia of cerebral atrophy is progressive and 



500 MEDICO-LEGAL RELATIONS 

deepening while the post-apoplectic dementia is most marked 
immediately after the individual is roused after the attack, 
and gradually improves as the physical condition improves. 
The dementia of cerebral arteriosclerosis proceeds more slowly 
than the dementia of atrophy or softening and there are remis- 
sions. The dementia of cerebral softening is progressive and 
proceeds rapidly to complete obliteration of mentality. These 
would all be classed as senile dementia yet they differ in the 
extent and permanence of the mental impairment. A year 
after the recognition of senile dementia due to atrophy, the 
mind may still be sufficiently alert to understand and determine 
the provisions of the instrument that is being drawn. If it is 
a case of dementia due to softening a year after its inception 
(the embolic or thrombotic stroke) the mind is so profoimdly 
impaired as to be incapable of comprehending the acts per- 
formed. A year after an apoplectic stroke the mind is com- 
paratively clear. If a will is made a year after the appearance 
of the manifestations of dementia due to cerebral arterio- 
sclerosis, it will be necessary to determine whether the will was 
made during a lucid interval or not. Not only is the dementia 
of arteriosclerosis profound but it is often associated with delu- 
sions or illusions. The terminal dementia which may occur in 
old age is the closing stage of other forms of insanity and needs 
no further comment, for there is no question about the testa- 
mentary incapacity when insanity has advanced to this stage. 
Various forms of insanity may appear in the aged but they are 
generally carried over from earlier life and are in an advanced 
stage when the individual reaches old age. Certain forms of 
mental derangement are peculiar to old age. Oikeiomania, an 
unreasonable hatred of one or more members of the family, is 
a rather frequent form of mental aberration. Beginning in a 
real or fancied slight or neglect on the part of some member of 
the family, the individual broods over it, dislike is aroused which 
develops into hatred, sometimes involving several members of 
the family. Later fears and persecutory delusions follow. The 
individual may be rational in every other direction but this 
one delusion impairs his judgment in one of the most vital 
points involved, namely, in making a will. (Contrary decisions 
have been rendered, however.) A will may be valid if an exist- 
ing delusion does not interfere with the disposition of the prop- 



MEDICO-LEGAL RELATIONS 5OI 

erty. Delusions of grandeur are almost invariably associated 
with delusions of wealth, making the individual incapable of 
comprehending the real extent of his property. Where this 
exists the will shows internal evidence of mental derangement. 
The paranoic forms natural sequences and draws logical con- 
clusions from a basic proposition which is an insane delusion. 
In his will he makes a rational disposition of his property, 
selects proper beneficiaries but he will dispose of vast sums he 
does not possess. A will made by a paretic during a lucid in- 
terval gives no evidence of insanity and unless other factors 
exist to invalidate it, it will be admitted. If made during an 
insane period it is incoherent, containing irrelevant comments, 
trivial bequests and other evidences of mental derangement. 
The disease, however, is rare in old age and when it occurs, the 
dementia proceeds rapidly, rendering the individual virtually 
incapable of making a will. As the mind becomes weakened, 
insane ideas become less extravagant, imagination is less active 
and there is mental confusion. Confusional insanity with and 
without delusions and hallucinations is occasionally found in 
the aged. In these cases mental concentration is impossible and 
the individual is incapable of making a coherent will. 

What has been said of wills applies as well to other contracts 
and documents. The law does not recognize senile dementia 
other than as a form of insanity. The individual is either sane 
or insane, competent or incompetent, having sufficient mental 
capacity to make him responsible for his acts and make such 
acts represent his purpose and intent, or having not sufficient 
mental capacity to make him responsible for his acts and the 
acts valid. There is no border state in law, as there is in the 
medical aspect of the mental condition of insipient senile demen- 
tia and other conditions which we call the border state. The 
aged in the incipient stage of dementia frequently perform acts 
the nature of which they comprehend, but the consequences of 
which they cannot realize, owing to weakened mentality. 
Opposing views have been expressed as to the responsibility 
of the individual in this state and personal opinion, sentiment 
and public policy toward such acts, rather than the medical 
view of the mental condition, determine the nattLre of the act 
and the responsibility of the individual performing it. A factor 
heretofore unrecognized in determining the state of mind of 



502 MEDICO-LEGAL RELATIONS 

an aged person is the profound change in mentality during the 
senile climacteric. The senile climacteric marks the transitional 
period from old age to senility and while it is in progress, various 
forms of insanity may appear. This critical period lasts for 
several months and as there are many lucid intervals during 
this time, failure to recognize it will result in differences in the 
opinions of examiners who may see the individual passing 
through this stage, at different times. The mind is exceptionally 
clear during a lucid interval but if there has been considerable 
mental strain, as would occur when under prolonged examina- 
tion, mental confusion appears and this is followed by delusions, 
maniacal outbursts, fits of depression, of crying or anger, confused 
or lost memory and perverted reason or judgment. There is 
no evidence of logical deduction, no rational or regular sequence 
in the character or order of these manifestations of insanity. 
Delusions are soon forgotten and new ones appear. There may 
be emotional exaltation at one moment, followed the next by 
calmness or depression. Memory is confused, recent and early 
events commingling and forming composite pictures which may 
give rise to delusions. During the senile climacteric there is 
sometimes a recrudescence of sexual desire which is not sup- 
pressed by reason or the sense of morals and this may give rise 
to sexual crimes. Oikiomania frequently develops during this 
time. Delusions of grandeiu- may arise but they are not the 
extravagant delusions found in paresis or paranoia, but rather 
exaggerated ideas of the indiivdual's importance or deeds. As 
the climacteric period gradually merges into the post-climacteric 
period or true senility, exaltation and depression give way to 
apathy, memory becomes more unstable, the reasoning power 
and judgment become weaker, delusions and other manifestations 
of mental derangement disappear and there is instead a progres- 
sive senile dementia. Undue influence is most frequently 
charged in senile cases and is based either upon temperamental 
supineness, intellectual impairment or weakened volition. 
The individual may be sane in every respect and it may be an 
evidence of his sanity that in order to be free from opposition, 
annoyance and worry he will leave to others the disposition of 
his property after his death. Under such circumstances the 
testator may make an error of judgment but there can be no 
question as to his intent or testamentary capacity. Cases 



MARRIAGE 503 

arise in which an aged individual, neglected by his family and 
cared for by strangers, makes the latter his beneficiaries. 
Such cases frequently lead to the charge of undue influence. 
If it can be shown that such strangers had poisoned his mind 
against his family, the inference is clear that they had designs 
upon the property and had used undue influence to obtain it. 
The case is different when the claimants are nephews or nieces 
or relatives still further removed, the testator had peculiarities 
which would have made him objectionable to them, and the 
persons taking care of him had done so in spite of the peculiarities 
and had given him the attention which made him comfortable 
during his life. Where undue influence is charged and intel- 
lectual impairment is shown, the decision will rest upon the 
extent of the mental impairment. The impariment may not 
be sufficiently marked as to destroy testamentary capacity, 
yet it may be sufficient to cause the individual to be easily turned 
from one purpose to another by suggestions of designing persons. 
Where weakened volition exists the individual will submit to 
insistent demands though made in the guise of suggestions. In 
these cases there is impaired judgment exhibited in the more or 
less complete dependence upon the judgment of others even in 
trivial matters. Where this condition exists a will drawn by 
the testator in favor of the person dominating him, and to the 
exclusion of others who have natural claims upon the testator, 
will be open to the charge of undue influence. 

MARRIAGE 

Most states have laws granting divorce or making mar- 
riage voidable or void on the grounds of insanity or physical 
incapacity at the time of marriage. One or the other of these 
causes is sometimes introduced to secure annullment of mar- 
riage \\^th an aged person. The question of insanity generally 
hinges upon the construction placed upon senile dementia as a 
form of insanity and to what extent the physiological deteriora- 
tion of the mind due to age has affected the reasoning faculties. 
This is discussed in the article on insanity. 

Mesalliances occasionally involve legal questions respecting 
the mental capacity of ^an aged person contracting such mar- 
riage. In most cases such marriages are contracted under 



5C4 MEDICO-LEGAL RELATIONS 

sexual stress, the individual finding in marriage the only means 
of gratifying unimpaired sexual desires. In the absence of 
other evidences of insanity a mesalliance does not show mental 
deterioration. 

Physical incapacity may be organic or fimctional, i.e., due 
to defective organs or to weakness in the power of erection. 
The law demands that it be shown that the incapacity is in- 
curable. In the coeundi impotentia senilis and in other forms 
of functional incapacity it is often possible to produce a tempor- 
ary improvement under appropriate treatment, though in 
senile cases we cannot expect to maintain this improvement 
for any length of time. The weakness of the erectile power 
keeps pace with or may proceed faster than the gradual weaken- 
ing of the organism and cure in the sense of complete restora- 
tion to the power of virile manhood is impossible. As the legal 
construction of the term "incurable," as applied to the annull- 
ment statutes of this state (New York) has not been decided, 
a nice question of law is raised whether the requirement of in- 
curability will hold, notwithstanding possible temporary im- 
provement. In other words does temporary improvement 
vitiate the sense of incurability. To the medical mind com- 
plete restoration of a normal function where that function was 
impaired or prevented implies a cure whether the restoration 
be temporary or permanent. Physical functional incapacity 
may be a relative impotence, the erectile power being impaired 
at certain times, under certain circumstances or in the presence 
of certain persons and not otherwise. This may occur in old 
age. From a medical standpoint it is impossible to declare 
functional incapacity incurable if the organs are normal. 

SEXUAL PERVERSIONS 

Sexual perversions are rather common in the aged and are 
due to either diminished power with undiminished desire or to 
a recrudescence of desire after power and desire had previously 
disappeared. The latter is generally a forerunner or early 
concomitant of senile dementia. The most prolific causes of 
sexual perversion in the young, depravity and inverted sexu- 
ality, are so rare in old age, that they can be practically elimin- 
ated. In the aged the causes are weakened mentality, dimin- 



SEXUAL PERVERSIONS 505 

ished control over the emotions and some circumstance produc- 
ing intense emotional excitement. 

Hypererosis due to recrudescence of desire leads to impul- 
sive acts like rape, especially upon children, and to bestiality. 
The offender does not realize the seriousness of his act nor does 
he seem to show much concern when caught in flagrante deHcto. 
Close investigation into the mental condition of such offender 
will usually reveal mental defects involving the reasoning 
power, the emotions and the will. In almost every case there 
has been a clean record without any evidence of moral degen- 
eracy until the commission of the crime. A peculiar feature of 
such offences is that the offender almost invariably selects a 
child about the age of puberty or younger, rarely an older one 
with whom the sexual act could be performed. These cases 
generally go to trial and unless the point is brought out that 
there is senile dementia, the offender is usually convicted. 
The following is a typical case. 

An inmate of a soldiers' home who had not been away from 
the institution for several years visited a relative in the city. 
Diuing the night he entered the room of a fourteen-year-old 
girl and attempted to assault her. The child ran screaming to 
her parents, who found the old man undressed in the child's 
room, although he had had plenty of time to get back to his 
own room during her absence. At the trial he denied all knowl- 
edge of being in the child's room and of the attempted assault. 
There was no mark of assault upon the child and the defense 
lay in discrediting the child's testimony. 

He was discharged through disagreement of the jury. The 
following day he practised masturbation in a physician's office 
during the absence of the latter and did not desist when the 
physician returned. Although he gave evidences of failing 
memory and other mental impairment at the trial, his attorney 
failed to take advantage of this line of defense. 

Outbursts of sexual fury during such recrudescence are 
liable to recur and for that reason where one has been guilty of 
an assault he should be kept under restraint. 

Where the reasoning faculty is unimpaired the individual 
knows that assault is a heinous offence which is followed by 
punishment. Even during an outburst of sexual fury with 
diminished restraint upon the sexual instinct, this knowledge 



5o6 MEDICO-LEGAL RELATIONS 

saves him from committing the crime of rape, but it does not 
restrain him from bestiality and this is the usual form of sexual 
perversion occurring during the recrudescence of desire in the 
aged. This rarely comes to light. In most cases the individual 
is imable to perform the sexual act and adopts extraordinary 
measures to gratify his desire. In one case an aged manufac- 
turer was found nude surrounded by a number of young women 
in like condition. When caught in the act he did not exhibit 
the slightest concern about his situation, yet he was able to 
conduct the affairs of a large factory and other commercial 
interests. Taken to a sanitarium he soon developed senile 
dementia with occasional sexual recrudescences. In another 
case a merchant was found by one of his family in a position 
depicted in a pornograph a number of which he had lying in 
front of him. The sight of these pictures aroused in him in- 
tense sexual excitement which he could not suppress or gratify. 
Thereafter the man was constantly guarded, he developed an 
oikeiomania (hatred of family), later obsession of persecution 
and senile paranoia. 

The other class of cases of sexual perversion, those in which 
there is gradual loss of power with undiminished desire rarely 
lead to impulsive acts, as outbursts of sexual ftiry do not occur. 
These cases lead to solitary vice, occasionally to bestiality, 
more often to marriage with an unsuitable person. 

In this class of cases there is no dementia and the individual, 
realizing his unfortunate condition, will often go to a physician 
for relief, invariably seeking restoration of power, never suppres- 
sion of desire. The marital relations sometimes involve legal 
questions, but the other perversions are carried on so secretly 
that they are rarely discovered. Efforts to prove insanity by 
showing an unsuitable marriage have been made but unless 
there are other evidences of mental impairment, this alone is 
not sufficient to establish insanity. 

MALINGERERS 

Malingerers are frequently found among the aged, who 
either feign disease or exaggerate symptoms of an existing 
disease to create sympathy. The so-called factitious diseases 
which are produced voluntarily by the patient are rare among 



MALINGERERS 507 

the aged, nor do the aged purposely aggravate their ailments. 
They dread the infliction of pain and will do nothing which 
might give pain or increase it, or endanger their lives. As 
most of them have slight aches and pains, a little stiffness in 
their joints, a little difficulty of sight and hearing, they exag- 
gerate their symptoms and in the weakened state of their minds 
the constant repetition and recital of their exaggerated symp- 
toms may cause them to believe that they really suffer as much 
as they say. No one can measure the amount of pain or dis- 
tress that a person feels, who has a disease which is ordinarily 
painful. The aged do not perceive pain as intensely as younger 
individuals, but they have a greater dread of it, the anticipation 
makes them more sensitive and if pain is inflicted their mental 
distress is greater. Under such circumstances a light tap is 
exaggerated into a blow, a mild breeze into a strong draught ; 
they cry before they are hurt and claim to suffer all the pains 
that accompany the real injury. This is not real malingering 
as the patient has the mental impression of distress and for the 
same reason the hysteric should not be classed as a malingerer, 
for the pain is a mental reality though there be no visible cause. 
The true malingerer knows he tells an untruth for a purpose 
which will benefit him. Unconscious imitation may give rise 
to malingering. An aged man found a new companion who had 
a limp. He walked a short distance with his new friend every 
day and gradually fell into the step and limp of the other. 
His family called his attention to his unnatural walk and the 
old man at once concluded that he had some nervous disease. 
He exaggerated his symptoms, limped worse than ever before 
and when examined by the physician he insisted that he had a 
pain in the leg. The physician made note of the location of 
the pain and at his next visit read the record of the case as he 
had taken it but located the pain at another point of the leg. 
The old man fell into the trap but held on to the limp. It 
was necessary to separate him from his friend, seciu-e for him a 
new companion with sound legs and frighten him with threats 
of hospital and operation before he gave up the limp. The 
aged malingerer is rarely actuated by fear of punishment and he 
will not go to the length of those who will produce a disease or 
aggravate one, but he will maintain his deception even in the 
face of uncontrovertible proof. When he feigns a disease it is 



5o8 MEDICO-LEGAL RELATIONS 

invariably one in which pain is an element, never one which 
might cause his removal to an insane asylum or a hospital. 
The pain is referred to his chest or abdomen rarely to the back 
or other position of the body which he cannot see. It is worse 
when the person believes he is under obseration, but when 
his attention is diverted he gives no evidence of distress and 
under such circumstances pressure can be exerted on parts 
which a moment before could not stand the slightest touch. 
In examining a malingerer who feigns a disease, too close 
investigation and the appearance of doubt on the part of the 
physician will tend to fix in the malingerer's mind the symptoms 
he has given and make it more difficult to clear up the decep- 
tion. In cases where deception is suspected the physician should 
have an assistant who without the knowledge of the person 
makes note of the spots where the patient says the pains are 
located. By directing attention to other portions of the body the 
malingerer will find other painful spots which should be noted 
in the assistant's record. The examination should be superficial 
without showing any doubt in the person's truthfulness. A 
second examination will usually bring out new painful points 
while the malingerer will have forgotten the location of the pain- 
ful points of the former examination or remember only those to 
which his attention had been directed. In some cases the patient 
will present the appearance of decrepitude. This deception 
is difficult of detection by direct examination. 

The person must be watched and caught unawares, or by 
arousing his emotions, either anger, joy or expectancy, a 
sufficiently powerful influence may be exerted to cause him to 
forget his assumed weakness. Threats of punishment, especially 
if the punishment involves pain, may cause him to betray 
himself. A few cases will be cited. A man aged seventy-four 
applied to the courts to compel one of his children to support 
him. He presented the appearance of extreme decrepitude, 
tottering along on his cane and requiring the assistance of a 
court attendent to help him to the witness chair. The case 
was decided against him and he was ordered out of the court 
room under threat of arrest. He went out without his cane 
and as spry as a young person. The aged mother of a prisoner 
appeared on the witness stand, her apparent weakness and 
scarcely audible voice arousing sympathy for her and her son. 



MALINGERERS 509 

When a later witness appeared against her son she abused 
him in a loud voice and it required some force to drag her 
from the court room. A woman aged seventy was receiving 
sick benefit from a society for total disability. She was ap- 
parently too feeble to walk and could go out only when assisted. 
A fire occurring in her house, she ran down two flights of stairs 
then remembering that she had forgotten something she ran 
back to her rooms and came out a second time alone. 

The aged frequently exaggerate the symptoms of minor 
ailments and unless they give unusual symptoms it is almost 
impossible to detect the deception. Occasionally a single dose 
of some disagreeable drug \\all cure the patient or make the 
symptoms so mild that the dose need not be repeated. It is 
barbarous to apply a painful test to an aged person suspected of 
malingering, as his purpose is usually nothing else than to gain 
more sympathy and attention. There are occasions when the 
threat of a painful test is justifiable, as when an aged person 
complains that he is being neglected by his family in spite of 
their most solicitous care of him, and spreads the charge broad- 
casr that they refuse to obtain for him medical attention, though 
there is nothing to indicate that he is ill except his complaints. 
Even here it is a question of humanity how far such threats 
should be carried out and how far the person should be humored. 
It is safe to say that when the patient will take disagreeable 
medicine and will submit to painful tests there is some basis for 
his complaints. 



INDEX 



Abasia, senile, 14, 147 

trepecante, 147 
Abscess, atheromatous, So 

brain^ 476 

liver, 459 

lung, 293 

retropharyngeal, 439 

spleen, 463 
AchyUa gastrica, 186 
Acne sclerotisans, 244 
Adams-Stokes disease, 170 
Ageing, causes of, 38 

manifestations of, 1 1 
Air embolus, 163 
Albumin, deficiency in blood, 431 
Albuminuria, 466 
Alopecia, 132 

Alternating arrhythmia, 173 
Alternating cerebral anemia and hyper- 
emia, 193 
Amentia, 252 
Anal fissure, 113 

sphincter, atony of, 113 
Anatomical changes in senescence, 

21 
Anemia and hyperemia, 376 
Anemia, cerebral, 193 

general, 429 

pernicious, 432 
Anesthesia, 153 

gustatory, 152 
pectoris, 174 

sine dolore, 175 
Angioma, serule, 231 
Angioneuroses, 242 
Amdrosis, 134 
Anorexia, 186 
Anosmia, 152 
Anuria, 465 
Aortic aneurysm, 83 

arteriosclerosis, ^2, 84 

insufficiency, 306 

stenosis, 309 
Aortite aigue, 80 
Aortitis, 83 

Apoplexy, cerebral, 198 
Appearance, 13 
Appetite, 105, 1S6 
Arcus senilis, 14, 36 
AiTh3rthmia, 171 

alternating, 173 

complete, 171 

exag-g-erated respirator}-, 171 

ex:risv5tGlic, 172 

zi:iiz-z, 173 

sinus. 171 

5 



Arterial changes, 25 

degeneration, 79 
Arteriosclerosis, 25, 74-94 

abdominal, 86 

aortic, 82 

cerebral, 84 

coronary, 83 

gastro-intestinal, 86 

hepatic, 86 

peripheral, 87 

pulmonary, 84 

spinal, 87 
Arthrosclerosis, 136 
Ascites, 461 
Asthma, 208 

Atheromatous abscess, 80 
Attitude, 14 

Auricular fibrillation, 171 
Autointoxication theory of ageing, 41 

Bacterial dermatoses, 239 
Biliarv' obstruction, 189, 329 
Bladder carcinoma, 282 

changes in senescence, 29, 34 

degeneration, 117 

dilatation, 117 

inflammation (see CystitU) 
Blood in senescence, 33 

in senile cachexia, 68 

pressure, 32, 52, 81 
Bone changes, 21 

tuberculosis, 416 
Brachial neuralgia, 267 
Bradycar^dia, 16S 
Brain, abscess of, 476 

atrophy of, 29 

changes, 29, 35, 140 

degeneration, 138 

fag, 35 (see also Cerebral) 
Breast, carcinoma of, 284 
Bromi'drosis. 134 
Bronchial asthma, 208 

stenosis, 446 
Bronchiectasis, 287 
Bronchitis, acute, 444 

capillary, 220 

chronic hypertrophic, 286 

senile atrophic, 178 
Bronchocele, 443 
Brown atrophy, 99 
Bulbar paralysis, acute, 379 

progressive, 379 
Bulimia, 186 



Cachexia Grawitz, 
malarial, 387 
senile, 67 



284 



II 



512 



INDEX 



Calculus, renal, 337 

vesical, 340 
Canites, 133 

Canstatt's theory of senescence, 43 
Carbuncle, 240 
Carcinoma, 268 

bladder, 282 

breast, 284 

female genital organs, 283 

gall bladder, 280 

intestines, 277 

larynx, 272 

lip, 270 

liver, 279 

lung, 273 

mediastinum, 274 

mouth, 271 

oesophagus, 274 

oral, 270 

pancreas, 280 

penis, 283 

prostate, 281 

rectum, 277 

scrotum, 283 

stomach, 275 

testicle, 282 

thyroid, 443 
Cardiac asthma, 208 

dilatation, 296 

diseases, treatment of, 317 

hypertrophy, 25, 294 

neuroses, 166 

thrombus, 160 (see also Heart) 
Cardiovascular disease, 74 
Cartilage changes, 23 
Causes of ageing, 38 
Cell evolution theory, 43 
Cerebral anemia, 193 

alternating anemia and hyperemia, 

193 

hyperemia, 376 

apoplexy, 198 

arteriosclerosis, 84 

diseases, 56, 475 

hemorrhage, 198 

softening, 195 {see plso Brain) 
Cerebrospinal meningitis, 417 
Childhood and old age, I 
Cholecystitis, 189 
Cholelithiasis, 188 
Cholera, 390 
Cholerine, 391 
Chorea, 264 

Cirrhosis of the liver, 456 
Circular insanity, 256 
Circulatory changes, 32 
Classification of diseases, 65 
Claudication, 87 
Climacteric senile, 18 
Colic, biliary, 189 
Colitis, 227, 455 
Colonic pouch, 28, 34 
Compression myelitis, 474 
Conception of old age, 17 



Constipation, 55, no 

Contracture tabetique, progressive 

atheromateux, 147 
Coronary arteriosclerosis, 83 
Coxitis, 348 

Countenance in old age, 17 
Cranial bone changes, 22 
Cystitis, acute, 342 

chronic, 341 

senile, 228 

Debility, senile, 67 
Degeneration of the bladder, 117 

of the brain, 138 

of the cord, 145 

of the cranial nerves, 151 

of the ductless glands, 127 

of the end organs, 150 

of the female genitals, 124 

of the gall bladder, 115 

of the heart, 95 

of the intestines, no 

of the kidneys, 116 

of the liver, 114 

of the lungs, loi 

of the male genitals, 120 

of the muscle, 134 

of the nerves, 150 

of the oral cavity, 104 

of the prostate, 122 

of the skin, 130 

of the spleen, 128 

of the stomach, 106 

of the thyroid, 129 
Delirium cordis, 171 

senile, 142 
Demange's theory, 40 
Dementia, acute, 252 

senile, 138, 251, 496 
Dermatoses, bacterial, 239 

glandular, 243 

parasitic, 239 

progressive, 243 

retrogressive, 243 

toxic, 238 

tubercular, 241 
Diabetes mellitus, 358 

complications, 374 
temporary, 359 

insipidus, 265 
Diagnosis in senile cases, 51 
Diarrhea, catarrhal, 227 

senile, 55, 226 

serous, 227 
Digestion changes, 27, 34 
Dilatation of bladder, 117 

of stomach, 108 
Diphtheria, 384 
Disseminated sclerosis, 149 
Dress, 491, 493 
Dribbling urine, 118 
Drugs in old age, 58 
Ductless glands, degeneration, 127 

diseases of, 443, 444 



INDEX 



513 



Duodenal ulcer, 450 
Durand Fardels theory, 41 
Dysentery, 388 
Dyspepsia, 106 
Dysphagia, 105 
Dyspnea in emphysema, 102 
Dyspragia intermittens angiosclerotica 
intestinale, 87 

Ear changes in senescence, 30 

symptoms in arteriosclerosis, 85 
Ecthema, 239 
Eczema, 236 
Edema hypostatic, 95 

laryngeal, 441 

pulmonary, 288 
Electrotherapy, 62 
Embolic cerebral softening, 196 
Embolism, air, 163 

cerebral, 196 

femoral, 163 

portal, 163 

pulmonary, 162 

renal, 163 
Embryocardia, 173 
Emphysema, senile, loi 
Empyema, 210 

End organs, degeneration, 150 
Endocarditis, acute, 403 

senile, 100 
Endothelial irritation, 78 
Enteritis, 450 

acute, 451 

chronic, 454 
Enteroliths, 322 
Enteroptosis, 321 
Epilepsy, 262 
Epithelioma, 247 
Erysipelas, 419 
Exercise, 481 
Exophthalmic goitre, 443 
Extrasystolic arrhythmia, 171 
Eye changes in senescence, 30, 36, 53 

symptoms in arteriosclerosis, 85 

Face in senile diseases, 53 
Facial nerve, degeneration of 151 
Fatty degeneration of the heart, 300 
of the liver, 459 

infiltration of the heart, 301 
Fear in the aged, 486 
Fecal impaction, 322 
Female genital organs, carcinoma, 283 

changes, 16 

degeneration, 124 
Femoral embolism, 163 
Fibroma, 246 
Flatulence, 113 
Folliculitis, 240, 244 
Food, 112, 183,368,478 
Furuncles, 240 

Gall bladder carcinoma, 280 
changes, 28 

33 



Gall bladder, degeneration, 115 

inflammation, 189 
Gall stones, 188 
Gangrene, pulmonary, 290 

senile, 164 
Gastralgia, 187 
Gastric asthma, 208 

atonicity, 106 

carcinoma, 275 

catarrh, senile, 180 

hyperesthesia, 186 

neuroses, 185 

ulcer, 448 
Gastritis, acute, 223 

chronic, 225 
Gastrodynia, 187 

Gastro-intestinal arteriosclerosis, 86 
Gastrospasm, 185 (see also Stomach) 
Generative organs, female, degenera- 
tion of, 124 
male, degeneration of, 120 
Glandular changes, 29 

dermatoses, 243 
Glossodynia, 105 
Glossopharyngeal nerve, degeneration 

of, 151 
Goitre, exophthalmic, 443 
Gonorrheal infection, 425 
Gout, 351 

irregular, 356 

regular, 352 

retrocedent, 352 
Goutiness, 356 
Grawitz' cachexia, 284 
Gustatory anesthesia, 152 

paresthesia, 153 

Hay fever, 207 
Heart block, 172 

brown atrophy, 99 

changes, 25, 26, 32 

degeneration, 95 

fatty degeneration, 300 
infiltration, 301 

neuroses, 166 (see also Cardiac) 
Heat regulation in senescence, 42 
Heberden's nodes, 348 
Hematuria, 466 
Hemicrania, 246 
Hemoglobinemia, 431 
Hemoglobinuria, 466 
Hemorrhoids, 327 
Hepatic abscess, 459 

arteriosclerosis, 86 
Hernia, 326 
Hidrocystoma, 243 
Histomechanical theory, 40 
Histopathological theory, 40 
Hobbies, 484 

Home care of the aged, 476 
Horsley's theory, 42 
Hydremia, 430 
Hydropneumothorax, 292 
Hydrotherapy, 62 



514 



E^DEX 



Hygiene, 476 
Hyperesthesia, 154 
Hyperidrosis, 134 
Hypertrichosis, 133 
Hypochlorhydria, 186 
Hypochondria, 252 
Hypostatic edema, 95 
Hysteria, 264 
Hysterical asthma, 208 

Illusions in arteriosclerosis, 85 
Impaction, intestinal, 322 
Impetigo, 239 

contagiosa, 236 
Impotence, 120 
Infarction spleen, 463 
Infectious diseases, 382 
Influenza, 401 
Insanity, 496 

circular, 256 
Insomnia, 61, 265 
Institutional care of the aged, 485 
Intestinal carcinoma, 277 

catarrh, 227 

changes, 28 

degeneration, no 

growths, 323, 326 

impaction, 322 

neuralgia, 188 

obstruction, 320 

occlusion, 325 

paresis, 323 

stenosis, 320 
Ischial neuralgia, 267 

Keloid, 246 

Keratoma, 232 

Kidney changes, 17, 28, 33 

degeneration, 116 

hyperemia, 464 (see also Renal) 
Kinks, 326 
Kyphosis, 15, 17 

Larynx, carcinoma of, 272 

edema of, 441 

inflammation of, acute, 440 
chronic, 285 
subacute, 441 

neuroses of, 442 

paralysis of, 442 

spasms of, 442 
_ syphilis of, 441 

tuberculosis of, 441 
Lentigo, 249 
Leukemia, 434 
Ligaments, changes, 24 
Lipoma, 246 
Liver abscess, 459 

amyloid, 459 

carcinoma, 279 

changes, 28 

cirrhosis, 456 

degeneration, 114 

fatty degeneration, 459 



Liver hyperemia, 458 

syphilis, 458 (see also Hepatic) 
Lorand's theory, 42 
Lung, abscess, 293 

carcinoma, 273 

changes, 27, 31 

degeneration, loi 

gangrene, 290 

tuberculosis, 411 (see also Pul- 
monary) 
Lupus, 241 

Malaria, 386 

Malarial cachexia, 387 

Malingerers, 506 

Mania, 255 

Marasmus, Schoenlein's, 72 

Marriage, 502 

Maxilla changes, 22 

Measles, 384 

Mechanotherapy, 63 

Mediastinal cancer, 274 

Medico-legal relations, 495 

Melancholia, 252 

Meniere's symptom complex, 471 

Meningitis, cerebrospinal, 417 

purulent, 476 

tubercular, 476 
Menopause, 16 
Mental changes, 14 37, 

in climacteric, 19 

disease symptoms, 56 

stimulation, 477, 482 

weakness, 38 
Metchnikoff 's theory, 41 
Metritis, 191 
Metrorrhagia, 342 
Miliaria, 243 
Miliary tuberculosis, 415 
Minot's theory, 43 
Mitral insufficiency, 311 

stenosis, 313 
Modified diseases of old age, 206 
Morbus coxae senilis, 348 
Motor oculi nerve degeneration, 151 
Mouth carcinoma, 271 
Mumps, 386 
Muscle changes, 13, 24 

degeneration, 134 
Muscular atrophy, progressive, 471 
Murmurs, 54 
Myalgia, 468 
Myelitis, acute, 474 

compression, 474 

senile, 146 
Myocarditis, 98 
Myofibrosis, 96 
Myositis, 470 
Myxedema, 443 

Naunyn's theory, 42 
Neoplasms, benign, 246 

malignant, 247 
Nephritis, acute, 467 



INDEX 



5IS 



Nephritis, chronic interstitial, 332 

parenchymatous, 467 
Nerve changes, 30 

degeneration, 150 
Nervous diseases, symptoms, 56 

system changes, 35 
Neuralgia, brachial, 267 

intestinal, 188 

ischial, 267 

occipital, 267 

trifacial, 204, 266 
Neurasthenia, 259 
Neuritis, 203 
Neuroses, cardiac, 166 

gastric, 185 

intestinal, 188 

laryngeal, 442 

oesophageal, 187 

of the aged, 264 

throat, 439 
Nevi, 246 

Occipital neuralgia, 267 
Oesophageal cancer, 274 

neuroses, 187 

spasm, 187 
Oikeiomania, 477, 479 
Oligemia, 429 

Optic nerve degeneration, 151 
Oral cavity degeneration, 104 

carcinoma, 270 
Ortner's syndrome, 87 
Osteitis deformans, 350 
Osteomalacia, 472 
Osteomyelitis, 474 
Osteoporosis, 21 

Pachymeningitis, 475 
Paget 's disease, 350 
Pain, 53 
Palpitation, 167 
Pancreas carcinoma, 280 

changes, 28 
Pancreatitis, 462 
Paralysis agitans, 377 

sine tremore, 378 

bidbar, acute, 381 
progressive, 379 
pseudo, 381 
Paranoia, 256 
Paraplegia, 146 
Paratyphoid, 399 
Paresis, general, 255 
Paresthesia, 150 

gustatory, 153 
Parorexia, 186 
Parosmia, 152 
Pastimes, 488 
Pelvic changes, 22 
Pericarditis, 447 
Perichondritis, 440 
Perisplenitis, 463 
Peritonitis, acute, 460 



Peritonitis, chronic, 461 
Pernicious anemia, 432 
Pernio, 238 
Pertussis, 386 
Phagocytosis theory, 41 
Pharyngitis, 438 
Phlcbosclerosis, 94 
Phthisis fibroid, 412 
Physiological changes, 31 
Pigment deposits, 131 
Pityriasis, 238 
Plague, 390 
Pleural cancer, 273 
Pleurisy, 209 
Pneumokoniosis, 103 
Pneumonia, infectious, 405 

senile, 216 
Pneumothorax, 292 
Pneumotosis, 185 
Polyneuritis, 471 
Portal embolism, 163 
Presbyacusia, 35, 36, 153 
Presbyopia, 35, 36, 153 
Preferential diseases of old age, 268 
Primary senile diseases, 67 
Proctitis, 455 

Progressive bulbar paralysis, 379 
muscular atrophy, 471 
enfeeblement, 135 
Prostate, atrophy, 124 
carcinoma, 281 
degeneration, 122 
hypertrophy, 122 
Prurigo, 238 
Pruritus senile, 154 
Psoriasis, 238 
Pseudo debility, 69 
Pseudo msomnia, 265 
Pseudo Paget's disease, 135 
Psychasthenia, 257 
Psychic changes, 37 

senile debility, 69 
Psychoses, 251, 255 
Pulmonary abscess, 293 
asthma, 208 
carcinoma, 273 
changes, 27, 31 
congestion, 214 
edema, 288 
embolus, 162 
gangrene, 290 

hyperemia, 214 (see also Lung) 
Pulse, 32, 52 

in arteriosclerosis, 81 
Purpura senile, 230 
PyeHtis, 468 
Pyemia, 421 
Pylorus, insufficiency, 109 

relaxation, 185 
Pyopneumothorax, 292 
Pyrosis, 185 
Pyuria, 467 

Raynaud's disease, 87 



5i6 



INDEX 



Rectal carcinoma, 277 
Reflexes, 36, 54 
Relapsing fever, 417 
Renal calculus, 337 

embolism, 163 
Respiratory changes, 27, 31 
Retropharyngeal abscess, 439 
Rheumatic arthritis, 346 
abortive, 348 
multiple, 347 
Rheumatism, acute, 419 

_ chronic, 344 
Rhinitis, acute, 436 

chronic, 437 
Rosacea, 234 

Sarcoma, 249 
Scarlatina, 383 
Schoenlein's marasmus, 72 
Scrotal carcinoma, 283 
Sebaceous nsevi, 232 
Second sight, 36 
Secondary senile diseases, 157 
Senile climacteric, 18 

slouch, 70 

stoop, 70 

tremor, 148 (see also terms having 
Senile as prefix) 
Sensations, 36, 53 
Sepsis, 421 
Septicemia, 421 
Sex perversions, 503 
Sight impairment, 36 
Sinus arrhythmia, 171 

thrombus, 159 
Skin changes, 24 

degenerations of, 130 

diseases of, 229 (see also Dermatoses) 
Sleep, 483 
Smell, 30, 36 
Social intercourse, 488 
Spinal column changes, 23 

cord changes, 30 

degeneration of, 145 
diseases of, 474 
Spleen changes, 28 

degeneration of, 128 

diseases, 463 
Splenoptosis, 463 
Spondylitis deformans, 348 
Stature, 14, 23 
Stomach, atonicity, 106 

carcinoma of, 275 

changes, 27, 34 

degeneration of, 106 

dilatation of, 108 (see also Gastric) 
Sudariperous glands, degeneration of, 

134 
Suprarenal glands, degeneration of, 129 

diseases of, 444 
Syphilis, 426 

larynx, 441 

liver, 458 

throat, 439 



Tachycardia, 169 
Taste, 36 
Teeth, 105 

Temperamental changes, 37 
Temperature in disease, 52 
Tendon reflexes, 36 
Theories of ageing, 39 

autointoxication, 41 

Canstatt's, 43 

cell evolution, 43 

defective heat regulation, 42 

Demange's, 40 

Durand Fardel's, 41 

glandular, 42 

Horsley's, 42 

histomechanical, 40 

imperfect repair, 42 

Lorand's, 42 

Metchnikoff's, 41 

Minot's, 43 

Naunyn's, 42 

phagocyte, 41 

Thoma's, 40, 75 

unstable metabolism, 42 

vital principle, 40 

wear and tear, 39 
Thoracic changes, 23 
Throat, diseases of, 438 
Thrombosis, 157 

cardiac, 160 

sinus, 159 

venous, 159 
Thrombotic softening of brain, 195 
Thyroid degeneration, 129 

diseases, 443 
Tongue cancer, 271 
Tonsillitis, 439 

Transmittory arrhythmia, 172 
Treatment in senile cases, 58 
Tremor senile, 148 
Tricuspid insufficiency, 314 
Trifacial neuralgia, 151, 204 
Tubercular dermatoses, 241 
Tuberculosis, 411 

acute general, 415 

bone, 416 

laryngeal, 441 

meningeal, 476 

miliary, 415 

throat, 439 
Typhoid fever, 392 
Typhus fever, 399 

Ulcer, chronic, 244 

duodenal, 450 

gastric, 448 
Unstable metabolism, 42 
Uremia, 465 
Urine changes, 33 

dribbling, 118 
Urolithiasis, 337 

Vagus degeneration, 151 
Valvular lesions, 302 



INDEX 517 

Variola, 391 Warts, 233 

Varioloid, 392 Wear and tear theory, 39 

Vascular changes, 25 Weil's theory, 77 

Veins varicose, 156 Whooping cough, 386 

Venosity, 27 Wills, 495 

Venous thrombus, 159 Wrinkles, 131 

Vesical calculus, 340 

Vicious circles, 35 Yellow fever, 387 

Vincent's angina, 438 

Vital principle theory, 40 Zoster, senile, 242 

Volvulus, 326 



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